Motivating Better Hygiene Behaviour: • Importance for Public Health

203.2 95M0

Motivating Better HygieneBehaviour:• Importance for Public Health

Mechanisms of Change

unkef 203.2 13025

Motivating Better Hygiene Behaviour:Importance for Public Health

Mechanisms of ChangeAuthors

Christine van Wijk and Tineke Murre,IRC International Water and Sanitation Centre,

The Hague, The Netherlands

Revised by Dr. Steven Esrey, UNICEF

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Table of ContentsAbstract 1

Introduction

What Difference Good Hygiene Makes to Public Health 3

Chapter 1

Why Conventional Hygiene Education does not Change Behaviour 5Chapter2

What Motivates People to Improve Hygiene 7

Chapter3

How Programmes Can Help 15

Chapter4

What Policymakers Can Do 25

References 27

Annex 1

Transmission Patterns and Preventative Measures for Water and Sanitation-related Diseases. .. 31Annex 2 R:~~~Ei~OEMotivating Improved Hygiene An Ahnotated Bibllogr ~ ~‘ 33lndextoAnnotatedB~bt~ôgraphy

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Abstract

E achyearoverthreemillion childrenundertheageof five die fromdiarrhoealdiseases.This, togetherwith

otherhealthproblems,including malnutri-tion, schistosomiasis,ascariasis,trachomaanddracunculiasis,result from risky hygienepracticesandinadequatefacilities fordomes-tic watersupply,sanitationandhygiene.Addressingthesehealthproblemsis of vitalimportancein achievingtheWorld SummitGoalsandtheWaterandSanitationDecadeGoalssetby themembercountriesoftheUnitedNationsandis partofthe policyagreedupon in February1993by theUNICEF/WorldHealthOrganizationJointCommitteeon HealthPolicy.

For thelast40 yearsUNICEFhassupportedthe provisionofwatersupplyandsanitationto populationsin need.In 97 countriesUNICEFhashelpedto introducelowcosttechnologieswhichhavebroughtbetterconditions,lower morbidityandmortality,timeandconvenienceto mfflions ofpeople.Nationalpolicieson waterandsanitationaredevelopedthroughadvocacyandworkingcloselywith nationalgovernments.

Currently,UNICEFis workingtowardsstrengtheningthe hygienecomponentinwatersupplyandsanitationprogrammes.Thereasonis thatimprovedwatersupplyandsanitationfacilitiesalonedo not auto-maticallyleadto their appropriateuseandtheadoptionof goodhygiene.However,addingconventionalhygieneeducationprogrammesto watersupplyandsanitationprojectsis no solutioneither.

Thispapersummarizeswhyconventionalhygieneeducationprogrammesfail inconvincingpeopleto adoptandusesaferhygienepractices.It discusseshowpeoplechangetheirhygienebehaviour,as individu-alsandin groupsandcommunities,andwhatmotivatingfactorsplaya majorrole intheseprocesses.It thenproceedsby present-ing two alternativetypesof hygienepro-grammesthataimespeciallyatgoodpracticesby 75% ofthepeoplein projectcommunitiesor 75% of thetargetgroupswhich togethermakeup the programme’saudience.Specialattentionis paidto rolesplayedby differencesin socio-economicandculturalconditionsandthe reasonsfor agenderapproachin all hygieneprogrammes.Thefinal chaptergivessuggestionsforpoliticiansandmanagers,stressingrecogni-tionandprofessionalizationof hygieneeducationprogrammes,moreresearchanddocumentation,especiallyon cost-effectivenessofprogrammes,andmoreopportunitiesfor exchange.

Thepaperhasbeenpreparedby the Interna-tional WaterandSanitationCentre,TheHague.It is onepaperin aseriesof publica-tionsdedicatedto theimprovementofhygieneprogrammesrelatedto watersupplyandsanitation.Theseries,whichwill includehygienecasestudiesandareviewof sanita-tion programmes,will formthebasisfor aJointUNICEF/WHOstrategyon hygieneeducationas partofimprovedwatersupplyandsanitationservices.Theserieswillculminatein JointGuidelinesfor ProgrammeImplementationof HygieneandSanitation.

Motivating Better Hygiene Behaviour: importance for Public Heaith Mechanisms of Change . 1

2 Motivating Better Hygiene Behaviour: Importance for Pubiic HealthMechanisms of Change

p

INTRODUCTION

What Difference Good HygieneMakes to Public Health

contaminatedhouseholdenvironmentandrisky hygienepracticesaccountfor almost30%of thetotalburdenof

diseasein developingcountries.Within thisgroup,75%of all life yearslostaredueto thelack of goodwatersupplyandsanitationandthe prevalenceof risky hygienebehaviour(World Bank,1993).

Thesecircumstancesandpracticeshavenotonly serioushealthconsequences,theyalsorepresentlargeeconomiclossesandnegativepublicity for countriesandgovernments.The choleraepidemicin Latin Americancities,with deterioratedwatersupplyandhygieneconditions,spurredpoliticiansandadministrators,who hadthoughtthediseaselongovercome,into action.The recentplagueepidemicin Indiacostthecountryanestimatedloss of overUS $ 2 million inexportrestrictionsanddecreasein tourism,andtherecentcholeraepidemicin Peru,15monthsin 1991—1992,costthecountry$200million in lostlives,decreasedproduction,exportsandtourism(SuárezR. andB.Bradford,1993).

Governmentstraditionallygive priority totreatingdiseasesthathavebecomemanifestandto immunizationof peopleagainstfalling ill. Yet, improvementsin watersupply,sanitationandhygienearethemostimportantbarrierto manyinfectiousdis-eases,becausewith safebehaviourandappropriatefacilities, peoplereducetheir riskofbecomingexposedto disease.

Governmentattemptsto preventexposurefocusmostlyonimprovingthequantityandqualityofdrinkingwater.Yet thegreatestpublichealtheffectscomenotfrom amounts

andqualityof drinkingwatersupply,but byensuringthatpathogenscannotreachtheenvironmentthroughthe unsafedisposalofexcretaor arewashedoff throughgreaterpersonalcleanliness.Researchby Esrey(1994)andEsreyet al. (1991)showedthatsaferexcretadisposalpracticeshadled to areductionof child diarrhoeaof up to 36%.Betterhygienethroughhandwashing,foodprotectionanddomestichygiene,broughtareductionin infantdiarrhoeaof 33%.Incontrast,commonengineeringgoalsofimprovingthewaterqualitylimited reduc-tionsin childhooddiarrhoeaby 15%to 20%.Reductionsin otherdiseases,suchas schisto-somiasis(77%),ascariasis(29%)andtra-choma(27%—50%)arealsorelatedto bettersanitationandhygienepractices,notjustatechnicallybetterwatersupply.Only thereductionofguineaworm(78%) canbetotally ascribedto betterwater.

Promotingbetterexcretadisposalandhygienehabitsarethe mostimportantmeasureto improvepublic healthandreducehumansufferingandfinancialloss.Yet mosttechnicalandhygieneeducationprogrammesdo not havethemeasurableimprovementofhumanpracticesas their primeobjective.Fundsfor behaviouralaspectsform only averysmallpercentageof investments,despitethe fact thathumanbehaviouristhekeydeterminantfor animpacton publichealth.If investorsandimplementorswantto getthefull benefitsfrom improvedwatersupplyandsanitationsystemsforpublichealth,theywillhaveto makeusageof improvedwater,sanitarydisposalof wasteandbetterhygienepracticesmajorobjectivesof theirpro-grammes.

Most waterand

sanitation related

diseases can only be

prevented by improving

a number ofhygiene

behaviours.

The most significant

appear to be:

• Sanitarydisposal of

faeces

• Handwashing, after

defecation and

before touching food

• Maintaining

drinking water free

from faecal

contamination.

Motivating Better Hygiene Behaviour: Importance for Pubiic HealthMechanisms ofChange 3

4 . Motivating Better Hygiene Behaviour: Importance for Pubiic Health Mechanisms ofChange

CHAPTER 1

Why Conventional Hygiene EducationDoes Not Change Behaviour

E ducationfor sanitationandhygieneisimportant.Accordingto theWHO,80% of infectiousdiseasesin develop-

ing countriesis relatedto inadequaciesinthesetwo areas.Improvedwatersupplyandsanitationfacilitieshelp,but their introduc-tion doesnot haveahealthimpactby itself.Properpracticesarethemostcrucial.

To promotebetterhygienepractices,manyhygieneeducationprogrammesfocusonincreasingpeople’sknowledge.Plannersandimplementorsassumethatwhenpeopleknowbetterhowwaterandsanitationdiseasesaretransmitted,theywill dropunhygienicpracticesandadoptimprovedones.However,thisis oftennot thecase.

Fallacy 1: Universal hygiene messagescan be givenPlannersandpractitionersofhygieneprogrammesoften think thatit is possibletogiveuniversalhygienemessagesto thepopulation.Suchmessagesareoftenbasedon the assumptionthatknowledgeof healtheducatorsis alwayssuperiorto local insightsandpractices.It is forgottenthatpeopleadapttheir lifestyleto localcircumstancesanddeveloptheir insightsandknowledgeoveryearsof trial anderror.

In Zambia mothers use a mixture of dark greenleaves, millet and fermented beans to weantheir children. This is cheap, easy, nutritious andgenerally known and does not depend on safewater for preparation. Replacing this practice bymore western notions of weaning foods for in-fants has brought a greater risk of diarrhoealdisorders and infant death than the local infantdiet (Gordon, in Stamp, 1990:34).

Generalhygienemessagesareoftennotrelevant,completeandrealistic.A typicalexampleis theoften givenadviceto boil alldrinkingwater.‘While scientificallycorrect,therearestrongindicationsthatboiling is

notalwaysneeded,becausepeoplebuild up aresistanceagainstthe lighterformsofwatercontaminationof their own watersources.Lackofwaterandsoapfor handwashingplaysabiggerrole in the transmissionofdiarrhoealdiseasesthanthedrinking ofunboiledwaterin one’sown environment(Feachemetal., 1986;Gilman andSkihicorn,1985; WHO, 1993a).

Tellingpeopleto boil their drinkingwater isalsounrealisticandincomplete.Boilingwatertakesalot of timeandresources.Womenmustcollector buymorefuel, waitfor thewaterto cool,storeit separatelyin aregularlycleanedstoragevesselanduseasafeway to drawit from thestoragevessel.Allthesestepsmustbe carriedout correctlyforthemeasureto be effectiveandthenit canstifi belessimportantthanwashinghandswith soapor ashes.

Fallacy 2 :Telling people what to dosolves the problemThemethodsthatareusedto gettheinfor-mationacrossarealsooftenunsuitabletocreatebehaviouralchange.Manyhealthmessagesaregiven in theformsof lecturesathealthclinics,talksin meetingsandgather-ingsandthrough one-waymassmedialikeposters,radio talks,brochuresandbooklets.Evenif theeducatorssucceedin reachingtheintendedaudiencesby thesemedia,thepeopleareonly‘told whatto do’ andoftendo not getthechanceto relateit to theirownexperiences.People“makesenseof newinformationin thelight of their own mean-ings,perceptionsandculturalbackgrounds”(RiversandAggleton,1993).If theydo notgettheopportunityto thinkit over, discussitandrelateit to their ownconcerns,thereislittle chancetheywill remembertheinforma-tion, let aloneapplyit.

Conventional hygiene

education messages are

oftennot relevant,

realistic and complete.

Boiling drinking water

is a typical example of

an incomplete and

unrealistic message

with a limited relevance

in many cultures.

Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms of Change 5

Fallacy 3: When people know abouthealth risks, they take actionManyhealtheducationprogrammesteachpeopleaboutwaterandsanitationrelateddiseases:whattheyare,howtheyarecausedandhowtheyareprevented.Buteducationdoesnot,by itself, reducethe risks of trans-mittingthesediseases,only actioncan.Andbetterknowledgedoesnot, in manycases,leadto action(BigelowandChiles,1980;Burgerset al., 1988;Doucet,1987;Dworking, 1982;Yacoob,1989).

Fallacy 4: Any improvements areequally usefulReviewofhygieneprogrammesshowsthatsettingof objectivesfor particularchangesisrare (Burgersetal., 1988).Hygienepro-grammesmaypromoteawiderangeofhygienebehavioursdown to cuttingnailsandcombinghairs.At thesametime, therearealso manyprogrammeswhicharelimitedto the promotionof the constructionanduseof onetypeof technicalintervention,suchasahandpumpor latrines,withoutaddressingotherhygienerisks.

Althoughactionis needed,it is not veryeffectivewhenaverywide rangeof behav-iours aretargeted,or only pointout themultitudeofplaceswherewaterandsanita-tion relateddiseasescan betransmitted(Figure1).Onewill haveto concentrateonthoserisksthatarecrucial in the transmis-sion of a particulardisease.

Accordingto currentepidemiologicalre-search,therearethreepracticeswhicharethemostcost-effectivein preventionoffaecal-oraldiseases(WHO, 1 993b):

1. Preventingfaecesfrom gainingaccesstotheenvironment;

2. Handwashing,afterdefecationandbeforetouchingfood;

3. Maintainingdrinkingwaterfreefrom fae-cal contamination.

Othercommondiseases,suchas schistoso-miasisandtrachoma,can alsobereducedsignificantlybybettersanitationandhygienepractices.

Improvedsanitation,betterhygieneandsafewatercanbeconsideredas threeseparate,butcomplementary,interventionsfor thepreven-tion ofthe transmissionof faecal-bornepathogens.Theprimarybarrier is improvedsanitation,or effectivecontainmentof faeces,by latrines,nappiesor othertypesof disposalfacilities. Thesepracticespreventpathogens,whichtravel with faeces,from gainingaccessto family compounds,watersuppliesandsoils.Buryingfaecesor disposingof faecesinlatrinesis alsobeneficial.Personalanddo-mestichygienecompriseasecondarybarrierto pathogentransmission.Handwashingafterdefecationandbeforehandlingfoodincreasethe chancesthatpathogensarewashedoff offood,handsandobjectsso theycannotenterpeople’smouthseitherdirectly from handsorvia food, objectsandwater.Handwashingis,however,only effectivewhenhandsarerubbedsufficiently andpreferablywith acleaningagent(e.g.,soap,ashes,soil or cer-tain typesof leaves).Justpouringwateroverhands,asis sometimesdone,is not effectivein removingpathogens(Boot, 1994).Theter-tiary behavioralbarrier is to makesurethatdrinkingwateris safeandclean.Many studieshaveshownthatwater,which is safefrom fae-cal contaminationatthesource,getscon-taminatedduring transport,storageandfromdrawingwaterin thehome(vanWijk, 1985).Drinking watercanbekeptcleanby makingsurethatthe storagepot,andthewaterwithin,cannotbetouchedby contaminatedhands,becausewateris drawnwith alonghandleddipperor from astoragevesselwith atap.

Increasing people’s

knowledge does not

automatically lead

them to change their

hygiene behaviour

FIGURE 1

Behaviours that reduce risks in transmittingwater and sanitation related diseases

washing.—floors, utensiIs~—.,_.~

protection with water& frequentof food cleaning agent washing of faces

handwashing drinking waterwith soap, drawn from safe

ashes, rubbing~~ sources with cleanf hands, vessel’

no open disposal Iofexcreta on land water sources for

or water” drinking, bathing\ protected from

pathogens’proper drainageof surface water

Store Safely collected‘Numberof stars gives general drawing of safely drinking watermagnitude of risk.Local conditions and stored drinkwater in safe manner’habitsdetermine which Improved without touching’practicels)will have the greatest impact.

6 . Motivating Better Hygiene Behaviour: Importance for Public HealthMechanisms of Change

CHAPTER 2

What Motivates Peopleto Improve Hygiene

I fgeneralmessagesandinformationondiseasetransmissiondon’t changepractices,whatis it thatbringspeopletotakeactionon therisky practicesandcondi-

tionsin their own environment?To answerthis question,alook is takenatwhathasbeenlearnedaboutinfluencingpeople’shealthbehaviourduringthelastfifteenyears.In the followingparagraphsit is discussedwhatprocessesmakeindividual peoplechangetheir hygienebehaviour.It is shownthatnewtechnologiesdo not necessarilybring thekind of benefitsthatuserslookforandthatmerelypromotingthesebenefitsfrom theviewpointof outsidersdoesnotmakepeoplechange.Subsequently,it isdiscussedthatbesidesindividualprocesses,groupprocessesandcommunityactionwillleadto behaviourchangeandthatto besuccessfultheseprocessesmustbeginatthestagewherepeopleseethemselves.The endof the chapterfocuseson thespecific factorsthatmotivatepeopleto adoptandsustainnewpracticesin personalandpublic hygiene.

Individual behaviour changeAuthorslike Baranowski(1992),Hubley(1993),Jolly (1980)andWhite (1981) lookatthereasonswhyindividualpeoplechangetheirhealthbehaviour.Theystressthatanynewhygienepracticesbeingpromoteddonot fall on emptyears.Peoplewhoareexposedto hygieneeducationprogrammesalreadyhavetheir ownknowledge,beliefsandvalues.Thesenot only comefrom theirownexperiences,but alsothroughsociallearningchannels(i.e., from parents,friendsandopinion leadersin the community).Often therearespecialnetworksfor sociallearningandin manycultureswomenplayanimportantrole in thesenetworksasprotectorsandconveyorsof local knowledge(Roark,1980).Hence,beforeadoptinganewhygienepractice,peoplewill askthemselves

howthenewpracticefits into their ideasandaffectstheir lives.

Hubley calls the processby whichindividualschangetheir healthpracticesthe BASNEFmodel (Figure2). Accordingto thismodel,an individualwill takeup anewpracticewhenheor shebelievesthatthepracticehasnetbenefits,for healthor otherreasons,andconsidersthesebenefitsimportant.He or shewill thendevelopa positiveattitudeto thechange.Positiveor negativeviews(SubjectiveNorms)from othersin hisor herenviron-mentwill also influencetheperson’sdecisionto try thenewpractice.Skills, timeandmeans(EnablingFactors)thendetermineifthepracticeis indeedtakenup, andwhenfoundto bebeneficial,is continued.

Lessons from technology projectsInsightson why individualschange,or donot change,their hygienepracticeshavealsocomefrom evaluationsof completedwatersupplyandsanitationprojects.As depictedintheleft handpartof Figure3, plannersandimplementorsof theseprojectsoriginallyhad

Behavioural change isa

process comprising

several steps, from

wanting to change and

deciding what change

to make to deciding to

try it out and if

positive, maintain it.

Before making the

actual change,

different

considerations (own

beliefs and values,

developed attitude,

influence ofothers,

enabling factors) play a

role.

F I G U RE 2

BASNEF model:How individuals change hygiene behaviour

(after Hubley 1993)

Beliefs about the consequencesofperforming a behaviourand value placed on each

possible consequence.

Behavioural intention —3 Behavioural change

Beliefs about whether otherpeople would wish person toperform behaviour and the Enabling factors

influence of theother person. (time, skills, means)

Motivating Better Hygiene Behaviour: Importance for Public HealthMechanisms of Change 7

averysimplifiedideaaboutthe relationshipbetweentheseinstallationsandpeople’shealth.Theyassumedthatjust designingandconstructingbetterfacilities would leadtoimprovedhealth.Whentheyfound thatafterinstallation,manypeopledid not usethenewfacilities, but continuedto usetheir tradi-tional watersourcesandpracticeopenairdefecation,the technologistscalled for healtheducation,to teachpeoplethe healthbenefitsof installedfacilitiesandgetthem acceptedandused.

However,whensocialresearchersbegantoinvestigatewhy thepeopledid not usethenewfacilities, theyinvariablyfoundthatfromtheir own pointof view, thepeoplehadverygoodreasonsfortheir behaviours.Not theusers,but theapproachof thetechnicalprojectshadto be changedto makegeneralacceptanceandhygienicusepossible(Melchior, 1989; Boot, 1991)

Thestudieson waterandlatrineusehavemadeclear thathygieneeducationcannotconvincepeopleto usefacilities thatdo notbring themnetbenefitsor do not functionproperly.Whathygieneeducationpro-grammescando is supportparticipatoryprojectsthatinstall facilitieswhich areusedandmaintained,by:

i) assessingif water,sanitationandhygienehavea highpriority amongthevariousgroupsin the communityandcreateun-derstandingofthe implicationsof existingconditions,technicaloptionsandmainte-nancefor communityandfamily health;

ii) beforeandafterfacilities areinstalled,fol-low up useandhygieneto providefeed-backto plannersandreduceothertrans-missionriskspreventingtherealizationofhealthimprovementsin thecommunitiesconcerned.

Community actionTheBASNEFmodelhelpsto understandhowindividualschangetheir hygienepracticesandstartto usebettertechnicalfacilities.Togetanimpacton health,suchchangeshavetobeadoptedbya largenumberof individuals.For reduceddiarrhoealdisease,for example,BatemanandSmith (1991)showedthatat

reduced diseasetransmission risks

Iimproved hygienic practices

Ihigh per cent used

.1hIgh per centmaintained

Ibetter facilities

CU RRENT THINKING

least75% of the populationshouldpracticegoodsanitationandhygiene.Suchbehaviourchangeevidentlyrequiresmuchtime andlong-termefforts.Moreover,certainpracticescannotbeachievedby individualchangealone,but requireconcertedactionfromlargergroupsandwholecommunities.Atypicalexampleis bettersanitationpracticesin schools.Poorschoolsanitationis often agreatrisk to the healthof thechildren.Butusingthetoiletsandkeepingthemcleanre-quiresmorethanthe individualbelief,will-ingness,time andmeansof thechildrenthemselves;gettinggoodpracticesfrom chil-drenneedsconcertedeffortsfrom not onlychildren,but alsoteachers,directors,admin-istrationandparents(WHO, 1994).

To reducetimerequirementsfor largescalebehaviourchangeandto addresschangesthatneedcooperativeaction,Isely (1978)andWhite (1981)haveadvocatedthecommunityapproachto hygienebehaviourchange.Themodelcombineslocalknowledgeof commu-nity membersaboutconditions,beliefsandresourceswith themorescientificknowledgeof thehygieneeducator.This combinationresultsin amorecompleteinsightfor allconcernedandleadsto abetterdefinitionofchangesandchoiceof strategiesthanwhen

F I G U RE 3Hygiene education

programmes cannot

coerce people to start

using facilities they do

not feel are suitable or

sustainable. However,

hygiene education can

play a supporting role

in technical projects by

creating understanding

of the (health)

implications of various

options and providing

follow-up for proper

use and maintenance.

Change ofconceptual thinkingon how technical projects contribute

to improved hygiene and health(after Melchior, 1989)

improved health

Iimproved health

better facilitiesORIGINALTHINKING


eitherpartyactsby itself (‘the wholeis largerthanthe sumof theparts’).

Making joint choices,assigningresponsibili-ties andmonitoringactionalso increasesthecommitmentofthemembersto achievetheagreedchanges.The representativenessof thegroupfor thevarioussectionsin the com-munity ensuresthatthepractices,views andcapabilitiesof eachsectionplayarole whentheprogrammeof changeis planned.It alsofacilitatesgettingcommitmentfor thechangefrom awide cross-sectionin thecommunitythroughexplanationandpro-motion by thegroup’smembers,andulti-matelyawider adoptionof thechangeby thecommunity(Figure4).

How adults learnIndividualsandgroupsnot only changetheirhygienepracticesunderinfluenceof changedbelief,attitudes,norms,technicalmeansandgroupprocesses.Adult educatorshavetaughtthatit alsomakesadifferencein whatlearningstageindividuals,groupsandcommunitiesarewhentheeducationalprocessstarts.Figure5 givesan overviewofthesestages.

If thepeoplefeel theyhaveno problem,it isnot usefulto try to tell them sowith alot ofinformationthatdoesnot fit into theirownway ofthinking.Beingpolite, theywillprobablyheartheeducatoroutwithoutdisagreeing,butwithoutanyrealdialogueandlearningtakingplace.In that caseit isoftenmuchmorefruitful to useothertechniquesandtools, suchasgamesandcommunalobservations,to helpthem defineif thereareanyproblemsrelatedto water,sanitationandhygiene,perhapsevenwith-out realization,andto determinewhetherthesecanbeaddressedby individualandcommunalaction.

Figure5 showsthatcomingwith concreteinformationis moresensibleandeffectiveaftermembersof the grouphaveconcludedthat thereis aproblemandareinterestedtodo somethingaboutit. Whentheyarereallyinterestedandtheideaissupportedbypeers,it oftenturnsout thattherearemorepossi-bilities for taking actionthantheparticularsolutionthefacilitator hasin mindandlocal

resourcesandcreativenessareloosened,ashappenedin thecaseof the waterdippersinKenya.

Women in a resettlement area in Kenya decidedto improve their water storage habits whenthey were convinced of the benefits of keepingdrinking water clean. They already kept drinkingwater in a separate and covered pot, but fordrawing, a communal cup was kept on top ofthe pot to dip into the water and drink from.Having discussed the risks of touching the waterwith soiled hands, the women decided to re-place the communal cups by longhandled dip-pers. Since itwas not easy to buy inexpensivedippers, they decided to bind off calabashes togive them a bottle-type shape and then cuteach calabash overhaif to produce twolonghandled dippers for water drawing (pers.exp. C. van Wijk).

For eachofthestagesin Figure5, it followsthatdifferenteducationalstrategiesareneededto meetdifferenteducationalgoals.Srinivasan(1992)distinguishesthreeeduca-tional strategies:didacticteaching,growth-orientededucationandeducationfor societalgrowth(Figure6).

• Didacticteachingequipspeopleas quicklyaspossiblewith theknowledgeandcopingskills theyarebelievedto lack. In didacticteaching,everyonelearnsthesamethings.Theeducatorchoosesthecontentsand

Communal behaviour

change is only possible

when the community

members themselves

feel there is a problem

andjointly undertake

action that will

permanently improve

the conditions and the

behaviours.

FIGURE 4

Community action model:How communities change hygiene

(after White, 1981:103-106)

lndigeneous capacities:representative group isinterested and knows practices,problems and possibilities

Community commitment:others are convinced throughexplanation and promotion

/L~.Jointchoice of relevant andr—’ feasible changes and strategy

NCommunalbehaviourchange

Hygiene educator capacity:brings in health knowledgeand organizational skills

/Community organization: targets areset and tasks defined and divided topromote and monitor change


When learning, people

remember 20% of what

theyhear, 40% of what

they hear and see, and

80% of what they

discover for themselves.(Hope and Timmel 1984:103)

methods,basedon what he/sheherselffindsimportantandthinksthepeopleneed.Modificationsof thedidacticmethod,suchas socialmarketing,first segmentthelearnersinto differentcategories,suchasmen!women,rich/poor,urban/ruralandaskthemabouttheirbeliefs,attitudesandbehaviours.Educatorsusethisinformationto adapttheirmessagesto eachsegmentedcategoryandtousechannelsandmaterialsthatwill reacheachcategoryandbe understoodandaccept-able to them.

• Growthcenterededucationis primarilyconcernedwith thedevelopmentof humancapabilitiesandan increasedsenseofhumandignity. Manydifferentgroupactivitiesareusedbywhichtheparticipantsacquireana-lytical, planningandproblemsolvingskills.The approachcan takemanyforms,but hastwo commonlyobservedprinciples:thegroupsmaketheir own decisionsandthefa-cilitatorkeepsa low profile. Bothprincipleshelpthegroupto identify their ownpriority

issuesanddiscoverandexercisepowersandtalentsavailablein thegroup,asillustratedbytheexamplefrom Kenya.

• Educationfor societalchangewasorigi-nally developedby PaoloFreire (1971). Itseeksto createcritical consciousnessamongthepoor.Thefacilitator first discoversthemesthataremeaningfulto thegroupandhelpsthegroupto analyzetheir situation.Thishelpsthegroupto gaincritical insightsinto the structuresofpoweranddeveloptheircapacityto organize.Theprocessculminatesin actionto restructureandcontroltheenvironment.

Whicheducationalstrategyis bestdependson thelearninggoalsandtheaudiencesof theprogramme.Quiteoften,a mix ofdifferentapproachesis used.The‘didactic mode’ isbestto transferknowledge— facts— toindividualsor largegroups.Massmediasuchaspostersandradio messagescanbeusedtoconveysimplefactsto largeaudiences,but

F I G U RE 5

Stages of readiness to change for individuals, groups and communities(Srinivasan 1990: 162)

lam willing todemonstrate thesolution to others and advocate change

I’m ready to try some action

7

There is a problem, but I am afraid~ ofchanging for fear of loss

2

1.

I see the problems, and lam interested inlearning more about it

Yes, there is a problem, but Ihave my doubts

There may be a problem —

but it’s not my responsibility

There is no problem

These responses areincreasingly open andconfident and come frompeople who are eager forlearning, information andimproved skills

Person has fearsoften wellfounded, about social oreconomic loss

Person skeptical about proposedsolutions — technical, sponsorship,capability, etc.

~nbelieves cause of problem and itssolution lie in the lap of the gods, orwiththe government, or some outside agent

Satisfied with things asthey are, sees no problem, no reason to change

10 Motivating Better Hygiene Behaviour: Importance for Public HealthMechanisms of Change

areusuallynot successfulin changingbehav-jour (Hubley,1993).However,whenmes-sagesarepracticalandconcreteandconveyedin anentertainingmanner,theycanbeusedto startoff discussionsamongfamily, peersandfriends,andevenleadto behaviourchange.

Lack of appropriate excreta and garbage dis-posal results in polluted water sources and is acommon cause of water-related diseases in In-donesia. A radio programme for farmers’women used a dialogue between two farmwomen to promote practical understanding andsanitary self-improvements. Broadcasts were ata suitable time (5:30 a.m.) and in the women’sdaily language. The scenarios were based onmeetings and interviews with the target groupbefore each series of broadcasts. In a survey lis-teners reported better knowledge and practices,but there were no before! after observations toconfirm these results (Aini, 1991).

The‘conscientization’and‘growth-centeredstrategy’arebetterto acquiredecisionmakingandproblemsolving skills.Theyputmoreemphasison theprocessoflearning.For this, theyuseparticipatorylearningmethods:participantsarestimulatedto thinkfor themselvesandto discoverunderlyingprinciples,throughgroup-discussions,gamesandrole-playsin smallgroups(10—25persons).During theseactivitiesthepartici-pantsdrawfromtheir ownexperiencesand

areencouragedto think of possiblesolutionsadaptedto their beliefsandpractices.

In conclusion,betterfacilities andhygienemessagesrarelychangepeople’shygienebehaviourby themselves.Peoplechangetheirbehaviourwhentheywantandcan do so fortheir ownreasons.Theyalsochangewhenchangeis partofa communaldecisionprocessbasedon the educationalstagethegroupor communityis in. In thisprocess,themembersthemselvesdecidewhattheywill changeandhowtheywill promoteandachievethe change.The hygieneeducatordoesnot directthechangebut helpsthemtochoosethekeychangesandorganizetheprocessof change.Insight into the specificfactorsthatmotivatesuchchangescanhelpto promotethisprocess.

Motivational factorsWhenpeoplechange,asindividualsorthroughgroupaction,whichspecific factorsmotivatethemto do so?In Table 1, four keybenefitsarelistedwhichhavebeenfoundtostronglyinfluencehygienebehaviourchange.Theyare: facilitation,or makinglife easier;understanding,in one’sownmodeof think-ing, thatthe changeis betterfor oneselfandone’sfamily; influenceandsupportfrom oth-ers,whenanewpracticeis adopted,andau-tonomy,or themeansandcontrolto carryout thepractice.

FacilitationFacilitation,or makinglife easier,is themostpowerful reasonwhypeopleadoptnewhy-gienefacilitiesandpractices.Newwater-

Four major factors

stimulate people to

change behaviour:

facilitation, practical

understanding,

influence from others,

and capacity to change.

Facilitation is usually

the most powerful

reason, since the

apparent benefits of

such actions are greater

than the less positive

consequences.

F I G U RE 6

Three educational strategies(adapted from Werner & Bower, 1982)

Didactic education Growth-centered education Education for societal growth

Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms of Change . 11

When facilitating

behaviour change,

sustainability is a

particular concern.

It is best to advocate

changes that are

sustainable at the local

level or create the

necessary skills and

capacity to improve

self-reliance.

C

points,for example,usuallyonly competewith existingwatersourceswhentheyarecloserandcanbeeasilyused,or involvelittleextratimeandeffortsfor watercollection.Iftheseconditionscannotbefulfilled, protec-tion of traditionalwatersourcesor facilita-tion of watercollectionandstoragefromnewsourceswill berequired.Latrinesandothersanitationfacilities mustalsoreducetheproblemsof daily life for the users.Ex-cretadisposalproblemsofthe peopleareusuallynot relatedto healthrisks,but lackofprivacy,safetyandlongerdistancesto def-ecationareas.Moreover,designsandopera-tionhaveto beeasy(e.g.,smooth,easytocleanslabsandpan;waterfor cleaningandflushing;andwaterandsoap/ashesfor hand-washingnearby)andlatrinesusablealsobytheyoungerchildren.Hence,it is essentialtoknowwhat factorsthepeoplefind impor-tant,not whatis importantin the eyesofhealthofficials or programmestaff.

Thechallengein facilitationis to addressrelevantchangesandnot beoverambitious.Obviously,not all behaviourchangecanbeaddressedatthesametime. Priority there-forehasto be givento thosepracticesthatconstitutea serioushealthriskandareconsideredafelt needby the population.

In dry areas such as on a plateau in Mozam-bique a shortage of water often goes hand inhand with a high incidence of skin and eye dis-eases. It was not the diseases, but the scarcity of

drinking water and the long distances that werethe first need of the villagers. But when water-points were brought closer and a reliable andpredictable service was installed, water use in-creased for personal hygiene and the washingand bathing of children. A closer water supply oreasier watercollection thus brought a greateruse of water which lead to a significant reduc-tion in skin diseases (Cairncross and Cliff,1987).

To makebetterhygienepracticeseasier,manyprogrammeshaveissuedbasichygieneequipmentandmaterials.Distribution ofsoaphelpedmothersin a projectinBangladeshto improvehandwashingandsignificantly reducedthetransmissionofshigellosisfrom onememberof the family toanother(Uddin,1982).In Thailand,plasticcontainerswith tapsfacilitatedsafewaterstorageandbroughta significantreductionoffaecalstreptococciin finger-tip rinses(Pinfold, 1990).However,suchsubsidizedinterventionsarerarelysustainableovertimeandreplicablein alargerprogramme.There-fore, it is bestto advocatechangesthataresustainableatthelocal level, or to createthenecessaryskills andcapacityfor localproduc-tion of goods,sothatpeoplecanbe asself-reliantas possible(CairncrossinUNICEF, 1993).

UnderstandingThisfactordiffers fromthe moregeneralhealthknowledgewhich is oftenpromotedin

TABLE 1

Factors inducing peop’e to change their hygiene behaviour

Facilitation~

,

Water sources are closer, supply is reliable and predictable, collection easier andsafer. Excreta disposal problems of privacy, safety, bad smells, flies, workand use bychildren are solved. Solid waste and waste water nuisance from dirt, mud, rats andbad smells are reduced.

Understanding People conclude that within their own hygiene perceptions certain conditions orpractices are unhealthy and should be changed. People perceive economicimplications of unhygienic conditions.

Influence•

~

People gain prestige from their new behaviour. Others support the new behaviour /disapprove of different behaviour. The group/community commits itself to thebehaviour. People agree on specific punishments or rewards.

Autonomy ~

•~

Means (time, energy, finances, etc.) are available. The process provides valued skillsand resources. The users are free to use their skills and resources.

12 . Motivating Better Hygiene Behaviour: Importance for Public HealthMechanisms ofChange

hygieneeducationprogrammes.Healthedu-catorswho promotegeneralhealthknowl-edgeusuallyrelyon academicconcepts,suchasthepresenceof germsandthe symptoms,transmissionroutesandpreventionof waterandsanitation-relateddiseases.Educatorswhich aimfor people’sunderstandinghaveinsightinto andrespectfor localknowledge,practicesandbeliefsandusethehealthcon-ceptsandreasoningofthe peoplethem-selves.An exampleis women’sbeliefsandpracticeson watersourceselection.

Like manyof their fellow rural women, womenin a Tanzanian village classified and used theirwater sources based on physical characteristics,such as visual cleanliness, taste, flow andabsence of practices leading to contamination.On this basis, they preferred river water overhandpump water for drinking. Water from theriver had a better taste and was consideredpure, because it was collected at daybreak,when contaminating practices were not yet tak-ing place. Being restricted in their mobility, thewomen had not considered that upstream, oth-ers were using the river for washing and bath-ing and that as the water flowed, contaminatedwater could reach them in the morning. Havinganalysed this, the women concluded that riverwater was less clean than they had thought andadopted the handpump for drinking water(pers. exp. author)

InfluenceInfluencefrom othersis anothersetof moti-vationalfactorsfor adoptingnewhygienepractices(Baranowski,1990; Hubley, 1993).Peopletendto adoptor discardpracticesforwhichtheygettheapprovalor disapprovalfromrespectedpeople,or by whichtheycanmakeanimpressionon others.Forexample,ownershipanduseof latrinesis, apartfromconvenience,strongly associatedwith no-tionsof respectabilityandhigh status(vanWijk, 1981).Healtharguments,which exter-nalpromotersuse,usuallyplayalessimpor-tantrole in changingexcretadisposalhabits(Mukerjee,1990; Sundararaman,1986;Tunyavanichetal., 1987; Wellin, 1982).

Influentialpeoplecanbeoutsidersrespectedfor theirgeneralstatus,suchaspublic figuresor healthpersonnel,but alsofriends,peers

andlocal opinionleaders.Steuart(1962)found in a controlledexperimentthatdiscussionswith local friendshipgroupsweremoreinfluential in changingenvironmentalhygienepracticesthantheusualfilms,exhibitionsandtrainingof formallocalleaders.Opinionleadershipdifferspersubjectandis closelyrelatedto theinformalnetworksoflearningwhichexistin mostcultures(Roark,1980). In Indonesia,forexample,local midwiveswere foundto bemostinfluential on behavioursconcerninghealthandhygiene(AmsyariandKatamsi,1978).Within local learningnetworks,womenin particularhavealeadershiprole.Choosingopinion leadersfor promotinghygienehadapositiveeffect in aprojectinTanzania,while failureto do so haddisap-pointingresultsin aprojectin Guatemala:

Evaluation of the hygiene education pro-gramme showed that the village women hadchosen those fellow-women as hygiene pro-moters, who were already opinion leaders inhealth and domestic care. Criteria used in theirselection were so subtle that the project couldnot have made the same choice. These womenwere very effective motivators of environmentalchanges, which are the responsibilities ofwomen (Therkildsen and Laubjerg in van Wijk,1985:91). In villages in Guatemala, the healthcommunicators selected by the water commit-tee made little impact.The committee hadprobably selected them for their knowledge ofSpanish and not for a role in the community’sinformal health network (Buckles, 1980:68).

A furtherinfluencefactor is theuseofpositiveandnegativesanctionsto stimulatehygienicbehaviourandreduceunhygienicpractices.Projectshaveusedgifts, subsidiesandpricereductions,aswell as materialincentives,suchascertificatesto stimulatechange(Burgersetal., 1988; ElmendorfandIsely, 1981).Finesandconditions(‘nolatrinesbuilt, no watersupplyproject’) havealsobeenused(Burgers,1988;Williamson,1983).Occasionally,communitiesrewardpositivepractices(FanamanuandVaipulu,1966),but moreusuallytheyestablishnegativesanctions,suchasfines.

While influence,statusandsanctionsareimportant,practicesadoptedonlyfor these

Experience shows that

practices adopted only

under the pressure of

others or for status are

sustained less than

when adoption is

motivated by factors of

facilitation and inner

conviction.

Motivating Better Hygiene Behaviour: Importance for Public HealthMechanisms of Change . 13

Even when people

agree to the new

behaviour because it

addresses a particular

problem, they may be

unable to change

present practices

because of lack of an

enabling environment.V

reasonsaresustainedlessthanwhenadop-tion is alsomotivatedby factorsof facilita-tion andinnerconviction.For example,assoonascontrolfrom healthinspectorsorpressurefrom an externalprojectto con-structanduselatrinesfell away,theywerenolonger,or onlypartially, used(Bigelow andChiles,1980; FelicianoandFlavier, 1967;PRAI, 1968;Williamson, 1983).

AutonomyHaving not only thedesirebut alsothemeansfor an improvedhygienepracticeis animportantstimulusfor anewhygienebehaviour.However,aswasseenaboveunderfacilitation,provisionof subsidizedmeansis often not alongtermanswer.Thisis whyanumberof hygieneeducationprogrammeshavefocusedon first creatingtimeandresourcesand/orhavetrainedthepeopleto producetheir own hygieneequip-ment,suchaswaterfilters, long-handledwaterdippers,dryingframesandlatrines(BoothandHurtado,1992; Curruthers,1978; Karlin, 1984; McSweeneyandFreedman,1980;Singh, 1983).

Havingthe resourcesfor changeis howevernot merelya matterof access,but alsooneofcontrol.In ‘The longpath’, MargaretJellicoe

describeshowyounggirls couldnot practicehygieneprinciplestheyhadlearnedin school,becausetheir husbandsdid not supportthem(Jellicoe,1978).And in a trachomapreven-tion programmemothersfelt theycouldnotspendextratime on collectingwaterandwashingtheir children’sfaces.Theywereafraidto becriticizedby theirhusbandsandmothers-in-lawfor neglectingtheir mainduty, namelyprovidingenoughfood for thefamily.

When the health workers found out that themothers did not want to wash the faces of theirchildren more often, because it would cost themtoo much timeto fetch the perceived extra wa-ter needed, they designed an exercise for the vil-lagers to see and try for themselves how littlewater was actually needed. Making it into acompetition, fathers managed to wash some 12faces with one litre of water and mothers morethan 30 faces. Everyone was surprised to findthat face washing needed much less waterthanpreviously believed (McCauley et al., 1990,1992).

Similarexperiencesin manyotherhygieneeducationprogrammeslearnthatmotivatingchangesin hygienepracticesalsomeanaddressingissuesof means,control andpowerin hygienepractices.

14 . Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms ofChange

CHAPTER 3

How Programmes Can Help

H ow arethe insightsdescribedaboveappliedin actualhygieneeducationprogrammes?Two typesof pro-

grammesaredescribed:programmesinwhich hygienechangesaremanagedby thecommunitiesthemselvesandprogrammeswhich usepublic healthcommunicationtochangehygienebehaviours.Eachtypeofeducationprogrammeis illustratedby acountrycasestudyon hygieneeducation;oneis thecommunityprogrammein Zam-bia, theWASHE project;the otheris apublichealthcommunicationandsanitationprogrammein Bangladesh.

Community-managed hygieneprogrammesIn community-managedprogrammesforhygienechange,trainedlocal or externalhealtheducatorshelpcommunitiesor localgroupsto establishandmanagetheirownprogrammesandorganizationsto realizethechangestheywant.In doing so, theyusethecommunityorganizationapproachto healthandhygiene,andinsightsandmethodsfromadulteducation.

Identifying key problems

In Figure5 it couldbe seenthatthebasisforplanningchangewith agroupor communityis thattheeducatorfinds out if the peoplethemselvesseeanyproblemsandthink it isnecessaryandpossibleto do somethingaboutthem. -

In smallan~homogenouscommunitiesit isoftenpossibleto do so togetherwith a singlerepresentativecommunityorganization,suchasawaterandsanitationor healthcommittee,whjchhasmaleandfemalerepresentativesof all groupsin thecommu-nity andincludesalsotheopinionleadersonhealthandhygiene.To find out who areopinionleaders,onecanmakeuseof focusinterviews(Box 1).Anotherpossibilityforidentifyingkeyproblemsin environmentalhygienepracticesandconditionsis to hold

local gatheringsfor assessingproblemsandgettingpeople’sviews. In largerandmoreheterogenouscommunitiesformingseveral,neighbourhood-basedconsultativegroupsorholdingseparateneighbourhoodmeetingscanbemorepractical.

Togethertheconsultativegroupsor partici-pantsofthe gatheringsandtheprojectstaffthenreviewthecurrentconditionsandidentify thosepracticesandriskswhich allagreeneedchangefirst. As seen,this requiresanunderstandingof whatmotivatespeoplefor wantingthesechanges:convenience,status,thelocal healthconceptsandthemeanstheyhaveto implementandsustainthechangesandreplicatethemby themselveswhenthecommunityexpands,sothatthepercentageof useis maintained.

In the WASHE project, the identification of hy-giene problems is done with the help ofunserialized posters. The posters are simple linedrawings made by a local artist. In the session,the project’s team spread the posters on theground and the participants select the onesthey want to discuss and place them in a mean-ingful sequence. The posters show local condi-

B OX 1

Focus group discussions

Focus group discussions are commonly used to findoutwhat the views and opinions of the variouspopulation groups in a community are (men,women, youths, different ethnic, economic andreligious groups), and who their opinion leaders onhygiene behaviourare. The health educatororganizes discussions with small groups of peoplein each group. The educator then engages thegroup members in free discussions on the desiredtopics by asking some key questions, drawingconclusions from the conversation between thegroup members. Focus group discussions requirean experienced interviewer who can put people atease, knows what she or he wants to learn andwhy, and is sensitive to slight contradictions(Dawson, 1992; Rudqvist, 1991).

In community-managed

hygiene programs,

trained health

educators help local

groups to plan and

manage their own

programmes and value

the changes they want.


Each village or urban

neighborhood will have

its own risky conditions

and practices. Bringing

together indigenous

knowledge and the

knowledge of the

hygiene educator helps

to select priorities for

change that combine

greatest felt needs with

greatest health impact.

tions and practices and also bring up issues ofmeans and control. Thus, some drawings showa very tired woman with a baby on her back,which frequently leads into a discussion on whymothers are tired and how this affects hygienepractices.

Theuseof participatorytechniques,suchasserializedposters,facilitatesactiveparticipa-tion of all andmakestheanalysismoreinter-estingandfun for everyonethanwhenjustdiscussionsareheld.Theyalsohelpmenandwomento useandenhancetheir practicalunderstandingon healthandhygieneandgive thehealtheducatorsmuchinsight in ashorttimein thehygieneconcepts,concernsandconstraintsofthe peopleandon thestageof problemdefinitiontheyarein, asde-

pictedin Figure5. Severalotherparticipatorytoolsfor thispurposearedescribedin Box 2.

Selecting prioritiesFigure 1 showedthatawiderangeof riskyhygieneconditionsandpracticesmayhavetobe changed.Eachwill posevaryingnuisancesandhealthrisksfor the community.All oftheseproblemscannotbe addressedatthesametime.Thus,it is usuallynecessaryto setprioritiesfor change.Bringing togethertheindigenousknowledgeandthe knowledgeofthe hygieneeducator,asdescribedin Figure4helpsto setpriorities for changewhichcombinelocally felt urgencywithgoodpotentialhealthbenefitsfroman epidemio-logical pointof view.

BOX 2

Participatory tools to create practical understanding

To identify risky practices, underlying beliefs, possiblesolutions and set priorities for change, severalparticipatory techniques can be used. (For theprinciples and more examples of participatorytechniques related to hygiene, see L. Srinivasan, 1990.)

with unresolved (hygiene) problems and 2 or 3 othercharacters giving him/her contradictory advice.What will he/she do?

Storywith a gapThe facilitator presents a poster showing a problemsituation and invites the participants to build a storyaround it, including possible reasons that causedtheproblem. He/she then presents a ‘problem-solved’poster and asks the group to think of steps the peoplein the picture took to solve the problem. If necessary,the facilitator distributes pictures of in-between steps.

Critical incidentThe facilitator presents three posters that illustrate aproblem situation and asks the participants to reflecton possible causes and solutions. Pros and cons ofdifferent options are discussed and conclusionsdrawn.

Interpretation of drawingsThe facilitator has a set of drawings with a range ofrisky conditions and practices in the particular area.The hygiene educator asks the group to discuss thedrawings and select those which depict practices forchange in their own community. These are then sortedin order of feasibility of change.

Pocket chart votingYet another technique is to hang drawings of riskyconditions on a wall with an open envelope undereach drawing. After discussing the meaning of eachdrawing, each participant is given five tokens toplace in envelopes under risks thought to be mostrisky (‘pocket voting’). In mixed groups, a gender-specific approach is possible by giving men andwomen tokens ofa different colour and summarizingreplies by gender. The same technique is also suit-able to assess the importance of hygiene changes incomparison with other development interests.Case-studies

The facilitator presents a case-study ofa risky hygienebehaviour as seen through the eyes of two groups ofpeople with different views. The participants reviewthe opinions of both groups and propose possiblesolutions.

Open-ended problem dramaThe facilitator presents two stories about problems acertain person faced, one problem was solved, theother not. The participants are asked to reflect on thestories and to fabricate a story about a different person

Environmental walkSuitable with smaller groups is to make an‘environmental walk’ and to visit all places whererisky practices may be found. Open and respectfuldiscussions on observed risks offer a goodopportunity to exchange knowledge and increaseappreciation of reasons underlying such conditionsor practices. It is fruitful to combine observationswith informal talks, because the two together canadd to a more complete understanding.

16 . Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms of Change

Selectionis doneusingthe sameparticipa-torytechniquesas before(unserializedpost-ers,pocketvoting,environmentalwalk),butnowaskingtheparticipantsto selectthemostimportantchanges.Wheremoregroupsareinvolved, commonpriorities canemerge.Apart from feltseriousness,alsode-greeof impact,local beliefson benefitsand

ability andcomplexityof changewill playarole,whenselectingkeypracticesfor changein thelocal situation.Box 3 givesatool forassessingthe feasibilityof hygienechangein aparticularcontext.Use of behaviouranalysisscaleshelpedahandwashingprojectin Gua-temalato selectchangesthatweremostcru-cial andrealistic (WHO, 1993a).

Partkipatory

techniques are excellent

tools to help people

realize problems, select

priorities, and plan for

change.

BOX 3

Criteria for evaluating likelihood of behaviour change

Using the criteriaFor each proposed behaviour change score 0-5 foreach of the nine sections. Aggregate the total scorefor each behaviour change. If the score for eachbehaviour is less than 20, it is highly unlikely that the

audience will make the change. Different goals mustthen be set. Ifthe score is over 36 it is highly likely thatthe goal will be achieved (Source UNICEF, 1993).

Health impact of behaviour0. No impact on health1. Someimpact

2. Significant impact

3. Very significant impact

4. Eliminates the health problem

Complexity of the behaviour0. Unrealistically complex1. Involvesagreatmanynumber

of actions

2. Involves many actions3. Involves several actions

4. Involves few actions

5. Involves one action

Positive consequencesof the behaviour1. Nonewhichmothercould

perceive

2. Little perceptible consequence3. Someconsequences

4. Significant consequences

5. Major perceptible consequences

Frequency of behaviour0. Must be done at unrealistically

high rate to achieve any benefit

1. Most be done hourly

2. Most be done every few days

3. May be done every few days4. May be done occasionally and

still have a significant value

Cost of engaging inthe behaviour0. Requires unavailable resources

or demands unrealistic effort

1. Requires very significantresources or effort/expenditure

2. Significant resources or effort3. Some resources or effort4. Few resources or little effort5. Requires only existing resources

Persistence0. Requires compliance over an

unrealistic long period or time

1. Requires compliance for a weekor more

2. Requires compliance for severaldays

3. Requires compliance for a day

4. Can be accomplished in a brieftime

Compatibility with existingpractices0. Totally incompatible1. Verysignificantincompatibility

2. Significant incompatibility

3. Some incompatibility

4. Little incompatibility5. Already widely practiced

Observability0. Cannot be observed by an

outsider

1. lsverydifficulttoobserve

2. Is difficult to observe

3. Is observable4. Is readily observed5. Cannot be missed

Approximations available1. Nothing like this is now done2. An existing practice is slightly

similar

3. An existing practice is similar

4. Several existing practices aresimilar

5. Several existing practices arevery similar


An important part of

planning is to choose

a few objectives for

measurable change in

hygiene conditions

and practices and

decide how their

achievements will be

measured.

Objectives, indicators and baselineHaving decidedon thetopicsfor behaviourchange,it is necessaryto choosethe objec-tivesanddeterminehowtheirachievementwill bemeasuredbeforethe programmestartsandasthework progresses.Thesettingof measurableobjectivesandthemonitoringof their realizationis oftenaweakelement:manyhygieneeducationprogrammesfocusonly on developingandmonitoringof inputs:thetypeandnumberof educationalmaterialsdevelopedandproduced,the typeandnumberof educa-tional sessions,thenumberof participants.This occurredin theWASHE project;onlyonevifiagecollecteddatabeforetheprojecthadbeencarriedout.

Baseline data from a hygiene study in Ilunduvillage on 23 April 1988 showed that thetwenty-one households had 1 pit latrine,2 bath shelters, 1 refuse pit and no dryingracks (Rogers, 1993).

To knowtheprogramme’sresults,thegroupsplanningthechangesneedto decidein thebeginningwhat theywantto achieve,whattargetstheyhaveandhowtheywillassessprogressandresults.Theusualprocedureis thatthegroupschooseafewhygieneobjectives,selectsomeappropriateindicatorsandcarryout abaselinestudytodeterminethesituationatthe startof theirprogramme.Indicatorsareneeded,becausenot all objectivesareeasyto measurein anobjectiveandvalid manner.Box4 givesan

Objective: General use of safe water sources, at least for drinking

Indicators: % of households with a protected waterpoint within competing distance of unprotectedones; no. of (recorded) timesthat theprotected waterpoints gave no water for more than aday. Unprotected sources no longer in use for drinking water; traditional sources remainingin use are protected.

Objective: Safe storage of drinking water in the homes

Indicators: % of households with a separatestorage container for drinking water present; with a coveron container; with long-handled dipper to draw water presentand above the floor; withoutcommunal drinking cup at the container; % of households whose hands cannot touch waterwhen demonstrating how theydraw water

Objective: Users keep the area around thewater sources in a sanitary condition

Indicators: % of waterpoints with a sloping slab and drainage channel, which works when tested; withdrain and surrounds free from garbage/sediments/mud/stagnant water; with a fence inplace and complete; a cleaning and caretaking system present.

Objective: Waste water is used for irrigating vegetable garden

Indicators: % waterpoints with garden, % households with garden in home compound, no. of gardenco-operatives formed and active

Objective: All households have and hygienically use sanitary excreta disposal practices;

Indicators: No visible human excreta in likely sites; % households with latrine present and observed tobe in use; % latrines with no soiling on walls and floors.

BOX 4

Measurable objectives and indicators for improved hygiene behaviours

Objective: Hands are washed with cleaning agent after toilet use/before cooking and eating

Indicators: Presence of water for handwashing in or near kitchen; presence of soap, ash or othercleaning agent near latrine and in kitchen

Adapted from UNICEF (1985) and monitoring system Morogoro/Shinyanga rural water supply and sanitationprogrammes (1990) in INSTRAW, 1991.


Indicatorswhich relyon observations,suchastheabsenceofhumanexcretaandthe pres-enceof longhandledwaterdippers,areusu-allymorereliablethanquestionsandeasiertouseby communitymembers.Careis neededthattheseindicatorsarevalid andreliable.In-valid observationshaveoccurredwhentheobserverinterpretedtheobservedphenom-enondifferentfrom whatit meant.For ex-ample,wateratalatrine maybe thoughtofaswaterfor handwashing,while in practiceit isfor analcleaningor for flushing.Problemsofreliabilityhaveoccurredwhentheobserverdefinedsomethingas cleanor unclean.Cleanlinessis quitea subjectiveconcept:whatoneobserverfindsclean,anotherfinds un-clean.Thedefinition of cleanlinessalsovariesovertime:the sameconditionjudgedascleanatthebeginningofaprogrammein Indonesiawaslater,whennormson cleanlinessbecamestronger,judgedasunclean.Objectivecrite-ria, suchas no visible smears,arethena morereliableindicator.A publicationby BootandCairncross(1994) gives moreinformationontheseandothermethodsfor measuringhy-gienebehaviours.

Deciding on activities, tasks and schedulesOncethe changeshavebeendecidedandobjectivesset,specific plansneedto beformulatedas to howthegroupwill bringaboutintendedchangesin thehouseholdsandcommunity,whatmotivationfactorsareusedandhowconstrainingfactorsaredealtwith. Emphasisis therebyput onwhatthehouseholds,groupsandcommunitiescan dothemselves,avoidinganylastinghelpfromoutsideto sustainchanges.

Latrinesareacommonexample.Often, newonesareno longerbuilt andexistingonesnotmaintainedandusedwhenoutsidesupportandmonitoringarediscontinued.In theWASHE project,emphasishasbeenplacedon promotingthosehygienechangesthat canbemadewith local means,suchas construc-tionandhygienicuseof simplehouseholdpitlatrines,buildingandkeepingschoolpit la-trinescleanandbuildingbathingenclosuresto promotewaterusefor personalhygiene.

Evaluating resultsPeriodicevaluationindicateswhatprogresshasbeenmadeandwhatchangeshavebeenrealized.

In Ilundu, one of the villages in the WASHEproject, an evaluation showed that between1988 and 1991, latrine coverage had increasedfrom 1 out of 21 households to 7; bathing shel-ters from 2 to 15, refuse pits from ito 13 anddrying racks from 0 to 13. No indicators weremeasured on the hygiene and use of latrines andbathing shelters (Rogers, 1993).

Pilesofunprocesseddatafrompreviousstud-ies demonstratethattheamountof dataandfrequencyof evaluationsarebestsetvery low.Participatorymonitoringandevaluation,in-cludingreasonsfor changeor non-changeareveryuseful,becausetheprocessalsohasastrongself-educatingeffect. But theyalsohavetherisksof too high expectationsfrom, andoverburdeningof, the groupscarryingout themonitoring,especiallythe women.Discussingthisbeforehandhelps,becausethewomencan thenchoosethosewho combinecommit-mentandinfluencewith moretimeandfree-domof movementandsuggestwaysin whichtheamountofwork canbereduced.Other-wise,additionaltechniquesareneededto en-ablethegroupor communityto measurechangesandusetheinformationfor thefur-thermanagementof thehygieneimprove-ment process.

Public health communicationprogrammesFor behaviourchange,apersonalapproachusingacombinationof motivationalfactorsisthemosteffective(Burgersetal., 1988;Hubley, 1993).But thisapproachalsore-quiresintensiveworkwith local staff, whoarewell-trainedin thevariousskills required.Thequestionis, therefore,if onecouldalsousethelarger-scaleandlessstaff-intensivemeth-odsof publichealthcommunication.

Programmesusingpublic healthcommunica-tion combinethe useof massmediawithpersonalcontactsto stimulatelargenumbers

exampleofarangeofbehaviouralobjectivesandindicatorsusedin variousprogrammes.

Progressis monitoredbyvillagersandpro-grammestaff.

In community-managed

programmes, a

community or

community group

makes the plan for

bringing about the

selected changes.

Educators only help.


Public health

communication

programmes

investigate target

groups on practkes and

views and select

channels, messages

and products most

suitable for each group.

of individualsandhouseholdsto changespecificbehavioursdirectly, withoutformu-lating theirownprogrammesandformingtheir ownhygienemanagementorganiza-tions. Theprogrammesfollow a systematicprocesswherebythekeyrisksareselectedandtargetgroupsareinvestigatedon theirpracticesandviewsandsegmentedintodifferentcategories.For eachcategorythedifferentchannels,messagesandproductsarechosenthataremosteasyto disseminateandconvincethegroupsconcerned,sothattheywill adoptthealteredbehaviours.

Public healthcommunicationhasbeenusedto promoteselectedpracticesin a numberofcountries.In HondurasandtheGambia,oralrehydrationfor childrenwith diarrhoeawaspromotedthroughmassmediabackedup bydemonstrationsandgroupmeetings.Thecampaignspromotedthe useofhome-mademixturesor ready-boughtpackagesdepend-ing on thecapacitiesof the targetgroups(Footeetal., 1983; Vigono, 1985).InBurundi,threemonthpromotioncampaignshavebeencarriedout by teamsofhygienepromoterswho visitedhouseholdsanddistributedprintedmaterials.Eachcampaignfocusedon threeselectedbehaviours,identi-fied from abaselinestudyof thetargetgroupsandwasevaluatedafterwards(pers.corn. I. Ntaganira).An extensiveprogrammeexistsalsoin Bangladesh.

The Bangladesh programmefor the promotionof sanitation and hygiene consists of threeinterlinked components: advocacy, to get sup-port for the programme from political and ad-ministrative leaders; social mobilization, to in-volve a wide range of actors, such as govern-ment staff, NGOs, schoolteachersand voluntaryorganizations in promotion activities, and apublic health communication programme. Un-derthe latter, standard hygiene promotionpackages are developed for the various types ofpromoters and target groups, each with a fewspecific messages based on field studies andsmall test projects (Boot, 1993).

Risk and audience studiesPublic healthcommunicationprogrammesfollow, acarefullystructuredapproach.Becausethe programmesaim atbehaviour

changeby largenumbersof individual peopleandhouseholds,theyfocuson the processesof individualbehaviourchangeandrely lesson participatoryanalysis,planning,organiza-tionandaction,whicharesoimportantincommunity-or group-managedhygienechanges.

In public healthcommunicationpro-grammesthe audienceis atthecentreof theprogramme.Beforedesigningthecommuni-cationpackage,it is first investigatedwhathygienerisksaremostcrucialandwhatbenefitsandmediawill motivatewhat groupsmostto adoptthenewpractice(s).InBangladeshthe mainhealthrisksfoundwerenot, aspreviouslythought,drinkingnon-tubewellwater,but absenceoflatrines,latrinesnot beingusedexclusivelyandhygienicallyby all family membersandlackof handwashingwith soap,mudor ash(Boot,1994). In Guatemala,handwashingby thosecaringfor children (mothers,oldersiblings)andsafehomestorageof drinkingwaterwereidentifiedas themostrisky practices(WHO,1993a).

Whatbenefitsareconsideredmostimpor-tant,whatmediaaremostaccessibleandappreciatedandwhatconstraintsneedto beovercomeis alsonotthesamefor all thepeople,but variesfor differentgroupsofpeople.To find themostsuitablemessages,productsandchannelsof communicationforeachcategory,publichealthcommunicationprogrammeplannerssegmenttheirpro-grammeaudienceinto differentgroups.Theytheninvestigatefor eachgroupwhat theydoandwant andwhatmeansof control theyhaveover theresourcestheyhave.The studygivesvaluableinformationon what messagesandproductsaremostrelevantfor eachgroup,whatan affordablepriceis andhowthemessagesandproductsaredisseminatedbestto reachandconvincemembersof eachgroup(WHO, 1993a).

In Guatemala the planners found that parentssaw clean children as attractive and happier, butnot necessarily healthier. Handwashing was be-lieved to be good, but enabling factors werelacking. Soap, water, towels were scattered andhandwashing placed demands on mothers’time, energy and resources. Mothers were inter-

20 • Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms of Change

ested in hygiene education. They wanted infor-mation materials in their own language and inSpanish and preferred 10 minute home visitsover large meetings. Approval from fathers wascrucial to make changes because fathers ob-jected to higher water consumption for hand-washing (Booth and Hurtado, 1?92).

ImplementationstrategiesPublic healthcommunicationseekstochangea few keybehavioursthat formthegreatestlocal risksin transmittingkeyhygienerelateddiseases.A limited numberofkeymessagesanda singleproductto facili-tatebehaviourchangeareselectedforreachingmanypeoplein alimited time. InGuatemalathesemessageswerehandwashingwith soap,togetherwith installinga ‘smartcorner’in the house,with soap,towelanda‘tippy tap’,asmallwatercontaineroriginat-ing fromAfrica that canbetippedupsidedownto drawwaterfor handwashing:InBangladeshthemessagesconcernhandwash-ingandconstructionanduseof pit latrines,togetherwith the buyingof a movablelatrineslabmadeandsoldin specialUNICEFproductioncentresandby privateentrepre-neurs.Promotionis by acombinationofspeciallydevelopedinformation,educationandpromotionpackagesandpersonalvisitsfrom developmentworkers,NGO staffandlocal voluntarygroups.Massmediamessagesarebroughtby influential public figuresfrom sport,films andpublic life. Smalltestsandregularstudiesgivefeedbackon thecost-effectivenessofthe programme.

Socio-economic and cultural contextMotivationalfactorsfor behaviourchangecan beappliedin all hygieneprogrammes.However, in operationalizingthemonehasto take into accountthatprogrammepopu-lationsareseldomhomogeneous,but belongto differentsocio-economiccategoriesandthatwhatmotivatesdifferentgroupsalsovariesfrom cultureto culture.Socio-economicdiversityin casteandclassexistsfor incomeandotherresources,suchaslandandwater,education,accessto communica-tion andlevel of power/influence.Culturerefersto the commonwaysofthinkingandactingofmembersof aparticularsociety,

their conceptson healthandhygiene,theirbeliefson howparticularillnessesarecausedandtransmitted,their arrangementsfortraining their children,their rolesfor menandwomen.

Socio-economicconditionsEsrey(1994) hasshownthatimprovedhygienepracticesonlyhavean impactonpublichealthwhentheycanandarebeingadoptedandsustainedby themajorpartofthewomenandmen,girls andboys.Hence,bothcommunitymanagedhygienepro-grammesandpublichealthcommunicationprogrammeswill haveto promotethosefacilitiesandpracticesthat solvethefeltproblemsandarewithin themeansof notone,but all socio-economicgroups.Inpractice,manyhygieneprogrammesreachonly thehigher-incomegroupsbecausetheyhavethetime, education,economicmeansandsufficientindependenceto try andadoptnewtechnologieswhichfacilitateimprovedhygienepractices.

Hygiene programmes withwomen’s groups, forexample, often mean that only higher classwomen are involved, because poor women arenot a member of these groups and have littletime for meetings, nor the means to adopt thepromoted practices (van Wijk, 1985: 93).

At thesametime,subsidiesandgiftswhichenablelower incomegroupsto practiceacertainhygienebehaviourareoften tempo-raryor onlyfor a smallgroup(Pinfold, 1990,Tonon,1980,Uddin, 1982).Forpermanentchangeswhich continuewithoutexternalsupportit is essentialthatimprovedhygienepracticesin projectvillagesbecomeasself-sustainedas possible.

How canoneensurethatpromotedpracticesandproductsareattractiveandfacilitative forthepoor,reachthem andbeadoptedbythem?Communitymanagedprogrammeshaveaddressedthisquestionby involving thepoorin the planningandmanagementoftheprogrammesandbaseprogrammeson theneedsandopportunitiesofall sectionsin thecommunity.Thishasled to variousadapta-tions, suchas choiceofothercommunicationchannels,promotionof practicesaffordableto all, introductionofcheapermodelsand

Both community-

managed and public

health communkation

programmes have to

ask what the felt

problems are and what

solutions are within

reach of all socio-

economic groups,

without dependence on

external subsidies.


Promotion of hygiene

requires understanding

of, and respect for, the

local culture.

helpfrom householdswith moreresourcesor from local authoritiesto householdswithlessresources.Publichealthcommunicationprogrammeshavetakensocio-economicfactorsinto accountby investigatingtheviewsandmeansofalsopoorpeopleandmakingsurethatmessages,productsandchannelswerebasedon their reality, whileincluding facilitationandstatussymbols.FelicianoandFlavier (1967), for example,mentionhowjet-shapedfootrestsbecameoneof the attractionsof their low-costlatrinedesignin the Philippines,while Pineo(1984)mentionshowawhite porcelainpotandnot theflushingmechanismmotivatedlow-incomeruralhouseholdsin Hondurasto havealatrinein their home.

Cultural influencesIn hygienepracticesandthe factorsthatmo-tivate peopleto changethesepractices,cul-tural conceptsalsoplayarole. Existinghy-gienepracticesdo not standby themselves,but arepartof moregeneralbeliefsandval-ues(e.g.,on contamination,privacy,trans-missionof diseaseandpreservingresources).

Hindu religion links practices on personal andenvironmental hygiene with notions on purityof the soul and rebirth in a better position. As aresult personal hygiene is strictlyobserved, butcleaning wastes is seriously hampered by thebeliefthat the action contaminates the soul andthreatens the chances to return in a better posi-tion in the next life. This is one of the reasonswhy a project in Northern India helps local the-atre groups and traditional singers to adjust re-ligious songs and drama so that their text andsymbols support new environmental hygienepractices (De et al., forthcoming)

Motivatingnewpracticesrequiresagoodunderstandingofthelocal culture.Pro-grammesthatpromotedbetterhygienein ar-easwherewaterwasscarce,asin theearliermentionedscabiescontrolprogrammeinTanzania,or expensive,asin thehandwash-ingprogrammein Guatemala,foundthatonereasonwhy theyweresuccessfulwasthatthepracticespromotedwerecongruentwiththepeople’svalueson economicuseof wa-ter. Researchinto cultural differenceswhichaffecthygienepracticeshasdevelopedsub-

stantially,resultingin greaterinsightsintothe varyingnormsandbeliefsregardingex-cretadisposal,foodandwaterboiling,andcausesof waterandsanitationrelateddiseases(Adeniyi, 1972; Curtis, 1977; Dube,1956;Khare,1962; Omambia,1990; Yoderetal.,1993; Zimicki, 1993)

GenderA culturalfactorof particularimportanceinimprovinghygienepracticesis gender.Genderis theculturallydefineddivisionofwork andareasof responsibility,authorityandcooperationbetweenmenandwomen.For everyimprovementrelatedto healthandhygieneonemustthereforeaskif it concernsmen,womenor bothandwhethereithercategoryhasspecificneeds,prioritiesandresources.Dealingwithgendermeansthatinpublic healthcommunicationprogrammes,menandwomenmustbe interviewedsepa-rately(Box 5) and,as in theGuatemalaprogramme,communicationchannelsandmessagesdevelopedforwomenandfor men.

A genderstrategyis alsoneededin commu-nity managedhygieneprogrammes,becausewhatmotivatesmento supportandadopthygienechangesdiffers from thefactorswhichstimulatewomen.Without agenderstrategywomenalsooftenfind that theirphysicalworkin hygienehasincreased,whiledecisionsandmanagementpositionshavegoneto the men(vanWijk, 1985).A genderstrategyhelpsmenandwomenbothtakepartin decisionsandfind commonsolutionsforconflictinginterests,asoccurredin NorthernGhana.

In a project in Northern Ghana, men and womendisagreed about the location of the new waterreservoir and wells. The young women preferredan area near to the village; the men were infavour of a location approximately two kms.from the village. Their main concern was to haveenough waterfor the cattle year round. Theolder women were divided. The project stafftried to convince the men of the benefits of thenearby location. They feared that, if the newwaterpoints were located far away, the youngwomen — who decide where to draw water —

would first use all ponds and pools nearby untilthese dried up and they would have to go to the

22 • Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms of Change

new wells to fetch water to drink. All pools!ponds in the area were guinea worm-infested,but still used, because the population did notbelieve they could get guinea worm fromdrinking infested water. Finally it was agreed tosituate the drinking water reservoir near to thevillage and improve the old dam for the cattle touse year round (Murre, 1989).

Whendealingwith gender,it is importanttonotethatwomenandmendo not necessarilybelongto homogeneousgroups,but mayhavedifferentconcernsaccordingto age,class,economicandeducationalstatusandethnicandreligiousgroup.It is not enoughto consultandplanseparatelywith menandwomenwithoutdistinguishingalsobetweenwealth,age,andothersocio-economicandculturaldivisionsin the society.

In the areasof domestichygienethe womenaremostinvolved. Theydo thework, takemanagementdecisionsin andaroundthehouse,educatethe childrenandarechangeagentsin contactswith otherwomen(ElmendorfandIsely, 1981; Roark,1980).Thereis, however,considerableevidencethatin managementdecisionsandwork concern-ing publichygiene,womenplaya greaterrolethanpreviouslythought(IRC andPROWWESS,1992).Casesfromthe Pacific,Nepal,Sri Lanka,Guatemala,Burkina FasoandEastAfrica demonstratethatwomen’s

involvementin waterresourcesmanagementis foundespeciallyin areaswith ashortageofwater,a strongwatercultureand/orastrongpositionof womenin healthmanagement(vanWijk, 1985).A casefromthe Pacificillustratesthispoint further:

In two of the three villages in Tonga, where asanitation programme had been started, thewomen had been left out from discussions toimprove insect control and excreta disposalmeasures. Afterinitial good progress theimplementation of the programme soon cameto a halt. Analysis showed that the project hadneglected women’s managerial roles in environ-mental health. Hence, in the third village, thewomen were invited to take part in the meet-ings to discuss the results of the social surveyand to plan the subsequent actions. Thewomen’s health committee was made respon-sible to implement the programme and taskswere divided between men, women andchildren. After three months, all families hadcompleted latrine construction and the evalua-tion after twelve months showed a generalupkeep of excreta disposal and insect controlmeasures (Fanamanu and Vaipulu, 1966).

Takingaccountof the centralrole of womenin healthandhygiene,it is logicalthatmosthygieneeducationprogrammeswork mainlywithwomen.Unfortunately,this meansthatin hygienechanges,menareseldomin-

Experience has taught

that both genders have

to be involved in public

and domestic hygiene

management and

decision-making.

BOX 5

Points to take into account when interviewing women(Wakeman, 1994)

When interviewing women, it is wise to keep certainprocedural guidelines in mind. Women interviewersare likely to obtain better access and more accurateinformation from women than would maleinterviewers. This is particularly the case wherewomen have limited social contact with men outsidetheir immediate family. The age, social class andcultural match of the interviewer have to beconsidered to make sure that the interviewer will betrusted and understood.

women may be unwilling to agree to this, even witha female interviewer, The possibility of groupinterviews wherever women gather (for instance, inmothers’ clubs, literacy classes oradult educationclasses for women) should be taken advantage of,particularly where these people already have a fairlyclose relationship with each other and can enter intoa lively discussion on the questions asked. Thistechnique will be particularly useful at the pre-feasibility stage during rapid assessment (wherethere is not always an opportunity for propersampling of the population nor for interviewing largenumbers of people). However, people who belong tosuch groups may not be representative of thepopulation as a whole; this needs to be kept in mind.

The interview situation is also important. Womenmay find it easier to answer questions in their workenvironment — the field, or the kitchen. Normally itis advisable to try to interview women when theirhusbands are not present, but in some cultures

Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms ofChange . 23

Men need to be

involved more in

hygiene programmes

to make investments,

change own practices,

reflect gender

divisions in physical

tasks and not burden

women with the sole

responsibility for

health and hygiene.

volved.Yet all hygieneprogrammesneedtoaddressmenaswell aswomen (Box 6). Onereasonfor a genderapproachin hygienebehaviourprogrammesis that for somedecisionsandchanges,womenalsoneedthecooperationofthemen.Decisionsforimprovementswhichrequiremonetaryinvestments,for example,arein manyculturestakenby themaleheadofthehousehold,or by maleandfemaleheadstogether(vanWijk, 1985:44)If menarenotwell-informedaboutthebenefitsoftheseimprovementstheyoftengivetheseim-provementsalow priority in comparisonwith otherneeds.

Moreover,for animpacton public health,malehygienepracticesalsohaveto change.

But in manyculturesit is difficult for womento influencemalehealthbehaviour.Thepro-grammesthushaveto addressmalessepa-rately, takinginto accounttheirbehaviourandresponsibilitiesandthefactorsthatmoti-vatethem to adoptbetterpracticesthemselvesandalsosupportimprovementsin thehouse-hold.Yet anotherreasonfor involving menisthatmanycultureshaveagender-baseddivi-sionoflabourfor certainimprovements,suchasthebuildingoflatrines,so thatimprove-mentis only possibleif menandwomenareinvolved.And finally, agenderapproachinhygieneeducationensuresthatextraworkandresponsibilitiesin hygienearenotshoul-deredbywomenalone,but that theyaredi-vided betterbetweenmenandwomen.

BOX 6

Six practical steps for a gender approach in hygiene programmes

• Assess with men and women what male andfemale hygiene practices need to be changed andwho has the responsibilities, authority and meansfor action.

• Choose and test key messages, products andcommunication channels for change on relevancefor and applicability by women and men.

• Assesswhether the programme addresses alsomen to improve their own hygiene practices andsupport hygiene improvements of their children andin their home and community.

• Get understanding and acceptance from men forwomen to take part in the consultation process andin management decisions and functions.

• Ensure that the programme does not increasewomen’s burden, but contributes to a better divisionof work, means and responsibilities between womenand men.

• Ensure equal representation of men and womenin training programmes and adjust training events toovercome cultural limitations for women’sparticipation.


CHAPTER 4

What Policymakers Can Do

A greaterfocusof hygieneeducationonmeasurablebehaviouralchangeandconsciousutilizationof the factorsin-

fluencingsuchchangealsorequiresgreaterthoughtandactionathigher levels.Thissec-tion discussesfour suchchanges:morecom-mitmentto healtheducationin general;greaterrecognitionandprofessionalisminhygieneeducationas aspecializationwithinhealtheducation;moreevaluationsandap-plied researchon howbehaviouralchangeisachieved,andmoredocumentationandex-changeof informationamongprofessionals.

Commitment and integrationProgrammeplannersandexternalsupportagenciesagreethatimprovedwatersupplyandsanitationaloneseldombringaboutfullchangesin hygienebehaviour.Hence,addinga healtheducationprogrammeis becomingmorecommon.

However,manyhygieneeducationpro-grammesstill havethecharacterof anadd-onto technicalinterventions.Fundsarelimitedandthereis little measuringof concretere-sultsbeyondthedevelopmentandproduc-tion of materialsandtheimplementationofeducationalactivities.

Anotherconsequenceof tagging-onhealthorhygieneeducationis that technicalandedu-cationalstaffdo not work asoneteamto-getherwith thecommunitiesandusers,buteachdoeshis or herwork parallelto, andun-influencedby, theother. Healtheducatorsusuallyhavetwo roles:preparingusersto ac-ceptwhattechnicalplannershave,decided,orchanginghealthbehaviourafterwardswhenthetechnologydoesnot resultin the desiredpractices.Thereis, however,muchevidencethathealthbehaviourswill not occuruntiltechnologiesareadaptedto practicesandre-quirementsof the users.The ultimateaimofengineeringprojectsis hygienebehaviourandthiscanonlybe achievedwhenworkingas oneteam,comprisedofhealthandsocialstaffandcommunitymembers.

Specialization and professionalismThe recentcharacterof hygieneeducationasa specializationprobablyexplainswhymanyprogrammestaffdealingwithbehaviouralaspectsin watersupply,sanitationandhygienedo not haveahealtheducationbackground.A smallsurveyamong43professionalsshowedthatonly six amongthemhadahealtheducationbackground,somethingwhichtheythemselvessawas oneof thelimiting factorsin theirwork (vanDriel, 1993).Moreover,within healtheducation,hygieneeducationis still littlerecognizedasavaluablespecializationandcareeropportunitiesarequite limited(Bertensetal., 1993).This situationmightimprovewhenhygieneeducationpro-grammesshowconcreteresultsandmovefrom the increaseof knowledgeto thedemonstratedimprovementof hygieneconditionsandpractices.

Capacity-building,which equipsprogrammeplannersandmanagersfor programmedevelopmentfocusingon measurablechange,is thusan essentialrequirementfor strength-’eningthispartof thewaterandhealthsectors.Severalactivitieshavealreadybeenundertakenin thisdirection.In 1991,WHO,UNDP, LondonSchoolof HygieneandTropical MedicineandODA organizedaworkshopon themeasurementof hygienebehaviour.The papersanddiscussionsof thisworkshophavebeenusedto prepareapracticaldocument(Boot andCairncross,1993).

Another recentdevelopmentis theestablish-mentof ashorttraining courseon planningandmanagementof a hygieneeducationprogrammeaspartof, or associatedwithwatersupplyandsanitationprojects(IRC,1993).Andon requestof the 29thMeetingoftheUNICEF/WHOJoint CommitteeonHealthPolicy,UNICEFandWHO aredevelopingajoint strategyfor hygieneeducationin watersupplyandsanitationforthe 1990s.

Strengthening the

professionalism of

hygiene educators and

adaption of a team

approach of engineers,

health staff and users

will optimize the

impacts of water and

sanitation projects.

Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms ofChange 25

Evaluations on use and

hygiene should become

a standard become a

standard part of all

implementation

programmes.

Evaluation and researchWhatsensedo watersupplyandsanitationprojectsmakewhenonlya smallproportionof thepopulationpracticesthebetterhygienewhichtheseprojectswereintendedtoproduce?Yet so far,very few watersupplyandsanitationorganizationstakethetroubleto find out the effectof theirwork on humanpractices.Theirresponsibilityendswith theestablishmentand,for watersystems,theexploitationof theservice;useandhygienefor all, whicharetheunderlyingdevelop-mentgoalsareseldominvestigated.

It wouldbe agreatimprovementif imple-mentingorganizationswould regularlycarryout or commissionevaluationson useoffacilitiesandhygienepractices,so thattheycanseewhattheyareactuallyachieving.Severalvaluabletoolsfor suchevaluationshavebeendeveloped,but so far thesearemainlyusedfor externalevaluations.Aware-nessraisingandcapacitybuilding for wateruseandhygienestudiesby implementingorganizationshavereceivedno financial andtechnicalsupport.

Besidesevaluationsthereis alsoa needformorefundamentalresearch.Very little isknownon whatarethemostcost-effectivemethodsin motivatingpeopleto changebehaviour.Whatis therole andeffectivenessof thefour mentionedmotivationalfactorsin public healthcommunicationpro-grammes?We alsoneedto knowbetterhowto dealwith genderdifferences,includinghowto developeducationalstrategieswhichalsochangemen,not onlywomen,foralmostall hygieneimprovements.Moreresearchon hygienebehaviourchangebymen,womenandchildrencanmakewatersupply,sanitationandhygieneeducationprojectsmoresuccessful.Theycanresultinbetterconditionsandpractices,which inturnwould resultin betterhealth,lowerhealthcosts,andgreaterproductivityduetolesssicknessin households,communitiesandcountries.

Documentation and exchange ofinformationTheremayyetbeanotherreasonwhysofewwatersupplyandsanitationprojectsandhealtheducationprogrammesincludemeasurablyimprovedhygienepracticesamongtheaimsof their programmes.This isthe sectorpractitioners’lackof accesstodocumentationon thisissueandtheabsenceof atradition to makeuseof documentedexperience.Mostorganizationsworkinginthesectordo not haveliteratureon hygieneandhygienebehaviourchangein theirorganizationsandif it is present,it is rarelyusedin designingprojects.Neitherdo staffhavethechanceto hearaboutsuchdevelop-mentsthroughtheir otherformsof informa-tion exchange,suchastechnicaljournalsandconferences.It wouldmakea majordiffer-enceif publishersofengineeringjournalsandorganizersof technicalconferenceswouldalsopayattentionto theimpactofinfrastruc-tureprojectson humanbehaviourandthewaystheseimpactsareenhanced.

Similarproblemsarefacedby thosedealingdirectlywith hygieneeducationin thewatersupplyandsanitationsector.Limited staff,lowbudgetsandhighimplementationpressuremakeit difficult to keepinformedofnewdevelopmentsandhavecontactswithcolleaguesdealingwith the sameissuesinotherprojects.It would, therefore,beagreathelpif agencieswhich financeimplementa-tion projectswouldgivethoseinvolvedinformulatinganddesigninghygienepro-grammestheopportunityto drawon existinginformationbeforetheydrawup andimple-mentanotherprogramme.If wewantwatersupply,sanitationandhygieneeducationprogrammesto result in improvedhygieneconditionsandpractices,weshallalsohavetoinvestmoreinto knowledgecompilation,useandexchange.


ReferencesAdeniyi,J.D. (1972). Choleracontrol:problemsof

beliefsandattitudes.InternationalJournalofHealthEducation,15, PP.238-245.

Aini, Fitri (1991).Radio showspreadsthewordsaboutwater,healthandsanitationtoislandsinIndonesia.PaperpresentedattheGlobalAssemblyonWomenand theEnvironment,Miami, Florida,4-8 November1991.

Alam, N. etal. (1989)Mother’spersonalanddomestichygieneanddiarrhoeaincidenceinyoungchildreninruralBangladesh.InternationalJournalof Epidemiology,vol. 18,(1), pp.242-247

Amsyari,F. & E. Katamsi(1978)Thestatusofhealthknowledgeandpatternsof seekinghealthadvicein ruralEastJava.InternationalJournalofHealthEducation,21(1), pp.34-40.

Baranowski,T. (1989/1990).Reciprocaldeterminismatthestagesof behaviourchange:anintegrationof community,personalandbehaviouralperspectives.InernationalQuarterlyof CommunityHealthEducation,Vol. 10 (4),pp.297-327.

Bateman,O.M. (1992). Diarrhoeatransmissionandhygienebehaviour:personalanddomestichygiene.Dhaka,InternationalCentreforDiarrhoealDiseaseResearch.

Bateman,O.M. & S. Smith. (1991). A comparisonof thehealtheffectsof watersupplyandsanitationin urbanandruralGuatemala.WASHField Report,No. 352,Arlington, USA, WASH.

Bertens,J. &Murre,T. (1993). Pursattown(Cambodia)Reportof aSAWA HealthandSanitationmissionMarch 10-20,1993.Ede,SAWA.

Bigelow,R.E. &L. Chiles.(1980). Tunesia;CAREwaterprojects:projectimpactevaluationreportno. 10 WashingtonD.C., USAID.

Boot,M.T. (1991).Juststir gently.Thewayto mixhygieneeducationwith watersupplyandsanitation.(TechnicalPaperseriesno 29).TheHague,IRC.

Boot,M. & S. Cairncross.(1993). Actionsspeak.Thestudyof hygienebehaviourin waterandsanitationprojects.London,LondonSchoolofHygieneandTropicalMedicine,andTheHague,IRC.

Booth,E.M. &E. Hurtado.(1992).Theapplicationofpublichealthcommunicationin waterandsanitationprograms.Geneva,WHO, Informalconsultation.

Buckles,P. (1980).Theintroductionofpotablewaterandlatrines.A casestudyof two ruralcommunitiesin Guatemala.Elmendorf,M. (ed.).Sevencasestudiesof ruralandurbanfringe areasinLatin America (AT Documentno.8).WashingtonD.C., USA, TheWorld Bank

Burgers,L. etal. (1988).Hygieneeducationinwatersupplyandsanitationprogrammes.(TechnicalPaperseriesno 27).TheHague,IRC.

Cairncross,S. andCliff, J. (1987).Wateruseandhealthin Mueda,Mozambique.TransactionsoftheRoyalSocietyof TropicalMedicineandHygiene,81,pp.51-54.

Curruthers,R. etal. (1978) Thesun,waterandbread:reporton anappropriatetechnologyworkshopin foodandnutrition.Ministry ofHealth,Nutrition Unit.

Curtis,D. (1977).The‘socialfactor’ in sanitationprogrammes.Paperpresentedattheconference‘Sanitationin DevelopingCountriesToday’OXFAM/RossInstituteof TropicalHygiene,Oxford,UK, 5-9 July, 1977.

Dawson,S. (1992). Thefocusgroupmanual.(Methodsfor socialresearchin tropicaldiseases,no. 1). Geneva,WHO.

Doucet,A. (1987).Womenandwater.Casestudiesfrom Latin America andtheCaribbean.InZandstra,I. (ed.),Seminaron theparticipationof womeninwatersupplyandsanitationprograms.(ManuscriptReportNo. 150).Ottawa,Canada,IDRC.

Dube,S.C. (1956).Culturalfactorsin ruralcommunitydevelopment.JournalofAsianStudies,vol. 16, pp. 19-30.

Dworkin, D. etal. (1980).Thepotablewaterprojectin ruralThailand(Projectimpactevaluationno. 3),Washington,D.C., USA,USAID.

Edungbola,L. etal. (1988).TheimpactofUNICEF-assistedruralwaterprojecton theprevalenceof guinea-wormdiseaseinAsa, Kwarestate,Nigeria.Am. J. Trop.Med.Hyg. 39 (1), pp.79-88.


Elmendorf,M. & R. Isely. (1981).Theroleofwomenasparticipantsandbeneficiariesin watersupplyandsanitationprograms.(TechnicalReportNo. 11).Arlington, USA,WASH.

Esrey,S.A. (1994). Complementarystategiesfordecreasingdiarrheamorbidity andmortality:waterandsanitationpaperpresentedatthePanAmericanHealthOrganization,WashingtonD.C.,USA,March 2-3.

Esrey,S.A. etal. (1991). Effectsof improvedwtersupplyandsanitationon ascariasis,diarrhea,dracunculiasis,hookworminfection,schisto-somiasis,andtrachoma.Bulletin of theWorldHealth Organization,Vol. 69 (5), pp.609—621.

Fanamanu,J. & T. Vaipulu. (1966).Workingthroughthecommunityleaders,anexperienceinTonga.InternationalJournalofHealthEducation,Vol. 9 (3),pp. 130-137.

Feachem,R. etal. (1986). Evaluatinghealthimpact:watersupply,sanitationandhygieneeducation.Ottawa,Canada,InternationalDevelopmentResearchCentre.

Feliciano,G.M. &J.M. Flavier. (1967).Strategyofchangein thebarrio,a caseof ruralwastedisposal.Lerner,D. & W. Schramm(eds.),Communicationandchangein developingcountries.Honolulu,USA, East-WestCentrePress.

Foote,D. etal. (1983).Evaluatingtheimpactofhealtheducationsystems.PaperpresentedattheNationalCouncilfor InternationalHealthCon-ference,WashingtonD.C., USA, 13-15June1983.

Freire,P. (1971). Pedagogyof theoppressed.NewYork, USA, HerderandHerder.

Gilman,R.H.& P. Skillicorn. (1985).Boiling ofdrinkingwater:cana fuel-scarcecommunityaffordit? Bulletin of theWorld HealthOrganization,Vol. 63 (1), pp.157-163.

HopeA. & S. Timmel. (1984).Trainingfortransformation:a handbookfor communityworkers.Gweru,Zimbabwe,MamboPress.

Hoque,B.A. &A. Briend (1991).A comparisonoflocal handwashingagentsinBangladesh.Journalof TropicalMedicineandHygiene,vol. 94,no. 1,pp. 61-64.

Hubley,J. (1993). Communicatinghealth.An actionguideto healtheducationandhealthpromotion.London,UK, TheMacmifianPressLTD. 1993

INSTRAW (1991). Trainingmoduleswomen,watersupplyandsanitation.SantoDomingo,DominicanRepublic,INSTRAW/ILO/UNDTCD.

IRC (1991).Partnersfor progress.(TechnicalPaperseriesno 28).TheHague,IRC.

IRC (1993).Shortcourseonplanningandmanagementof hygieneeducationprogrammes,aspartof, or linked to drinkingwatersupplyandsanitationprojects.The Hague,IRC.

IRC/PROWWESS(1992).Drinkingwatersupplyandsanitationprojects:impactsonwomen.Woman,Water,Sanitation(AnnualAbstractJournalNo. 2),The Hague,The Netherlands,IRC.

Isely,R.B. (1978).A communityorganizationapproachto cleanwaterandwastedisposalinCameroonianvillages.Progressin WaterTechnology,Vol. 2 (1/2),pp. 109-116.

Jellicoe,M. (1978).Thelongpath.A casestudyofsocialchangein Wahi, Singidadistrict,Tanzania.Nairobi,Kenya,EastAfrican PublishingHouse.

Jolly, P.W. (1980). Theimportanceofthehealtheducation:role ofthebehaviouralobjectives.Copenhagen,WHO.

Kanki, B. et al. (1991).Measuringhygienebehaviours:experiencesofa comprehensiveapproachin BurkinaFaso.A contributionto theworkshopon measuringhygienebehaviours,Queen’sCollege,Oxford,8-12April 1991.

Karlin, B. (1984). Communityparticipation,romanticismor reality?NewYork, USA,UNICEF.

Khare,R.S.(1962). Ritualpurity andpollution inrelationto domesticsanitation.TheEasternAnthropologist,Vol. 15, pp. 125-149.

McCauley,A.P. etal. (1990). Changingwaterusepatternsina waterpoorarea:lessonsfor atrachomainterventionproject.SocialScienceandMedicine,Vol. 31(11),pp. 1233-1238.

McCauley,A.P. etal. (1992). HouseholddecisionsamongtheGogo-peopleof Tanzania:determiningtherolesof men,womenandthecommunityin implementinga trachomapreventionprogram.SocialScienceandMedicine,Vol. 34 (7), pp. 8 17-824.

McSweeney,B & M. Freedman.(1980).Lackof timeasanobstacletowomen’seducation.ThecaseofUpperVolta. ComparativeEducationalReview,June,pp. 124-129.

Melchior, S. (1982).Women,waterandsanitationor countingtomatoesaswell aspumps.NewYork, USA,PROWWESS/UNDP.

Mukherjee,N. (1990). People,waterandsanitation:whattheyknow,believeanddo in ruralIndia. NewDelhi, India,NationalDrinkingWaterMission.


Murre, T. (1989).Village waterreservoirs.Half-yearlyreportanimationsection.Utrecht,Netherlands,SAWA.

Omambia,D. (1990). Changingsanitationpractices:asocio-culturalapproach.Nordberg,E.& Finer,D. Society,environmentandhealthinlow-incomecountries.Stockholm,Sweden,KarolinskaInstitutet,pp. 128-135

Pineo,C. (1984).Acceptabilityof Colombia-typewaterseallatrinesin Honduras.A studyofthecommunitypromotioncomponentof theruralsanitationprojectinBolivia. (TechnicalPaperNo. 121).Arlington, USA, WASH.

Pinfold,J. (1990). Faecalcontaminationof waterandfingertip-rinsesasa methodforevaluatingtheeffectof low-costwatersupplyandsanitationactivitieson faecal-oraldiseasetransmission:Ahygieneinterventionstudyin ruralnortheastThailand.EpidemiologyandInfectionno. 105,pp.377-389.

PRAI (1968).Inducedchangein healthbehaviour.A studyofa pilot environmentalsanitationprojectinUttarPradesh.Lucknow,India,Planning,ResearchandAction Institute.

Rivers,K. & P. Aggleton.(1993). Participationandinformation— whyyoungpeopleneedmoretimethan the ‘facts’ in HIV andAIDS education.InternationalJournalofHealthEducation,Vol. II(2), pp.22-25.

Roark,P. (1980).Womenindevelopment.Successfulruralwatersupplyprojectsandtheconcernsofwomen.WashingtonD.C., USA,USAID.

RogersRyan,J. (1993).HygieneeducationprogramminginZambia.Casestudy.NewYork,USA, UNICEF.

Roling,N. (1985). Extensionscience:increasinglypreoccupiedwithknowledgesystems.SociologicaRuralis,Vol. 25 (3/4),pp. 269-290.

Rudqvist,A. (1991). Fieldworkmethodsforconsultationsandpopularparticipation.(WorkingPaperNo. 9).Stockholm,Sweden,StockholmUniversity,Departmentof SocialAnthropology.

Singh,A. (1983).Employmentopportunitiesforruralwomenthroughorganization.NewDelhi,India, ILO.

Srinivasan,L. (1990).Toolsfor communityparticipation.A manualfor training trainersinparticipatorytechniques.NewYork, USA,PROWWESS/UNDP.

Srinivasan,L. (1992). Optionsforeducators.Amonographfor decisionmakersonalternativeparticipatorystrategies.NewYork, USA, PACT/CDS.

Stamp,P. (1990).Technology,genderandpowerinAfrica. Ottawa,Canada,IDRC.

Steuart,G. et al. (1962).Sanitationchangesin anAfrican community:astudyof primarygroupeducation.TheHealthEducationJournal,20 (3),pp.133-140and20 (4), pp. 198-205.

Suárez,R.and B. Bradford. (1993).Theeconomicimpactof thecholeraepidemicin Peru:anapplicationofthecostofillnessmethodology,WASH Field Report#415,Arlington, VA, USA.

Sundararaman,V. (1986).Thesocialfeasibilitystudyandtheroleof womenin ruralsanitation.Reportof thestudyin four villagesinMaharashtraState.Bombay,India, ResearchCentrefor Women’sStudies.

Tonon,M.A. (1980). Conceptsof communityparticipation.A caseof sanitarychangein aGuatemalanvillage, InternationalJournalofHealthEducation,Vol. 23 (4), Suppl.pp. 1-15

Tunyavanich,N. etal., (1987).Women,waterandsanitationin theruralNorthEastof Thailand.Bangkok,Thailand,Mahidol University,Facultyof SocialScienceandHumanities.

Uddin Khan,M. (1982). Interruptionof Shigellosisbyhandwashing.Transactionsof theRoyalSocietyofTropicalMedicineandHygiene,76(2),pp.164-168.

UNDP/WorldBank (1990).Rural sanitationinLesotho.WashingtonD.C.UNDP/WorldbankWaterandSanitationProgramandPROWWESS.

UNICEF (1993).Water,sanitation&hygiene~education:aUNICEF trainingpackage.NewYork, USA, UNICEF.

Vigano,0. (1985). Communication,communityandhealth.Tegucigalpa,Honduras,AcademyofEducationalDevelopment.

Wakeman,W. (1994.Genderissuessourcebook forthewaterandsanitationsector.Washington,D.C., USA, UNDP/WorldBankWaterandSanitationProgram.

Wellin, E. (1982). Socio-culturalimpactof wateronfar highlandcommunitiesin Peru.WashingtonD.C., USA, USAID.

Werner,D. & B. Bower. (1982).Helpinghealthworkerslearn.PaloAlto, USA,HesperianFoundation.

Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms ofChange 29

White,A. (1981). Communityeducationandbehaviourchange.In: Communityparticipationinwaterandsanitation:concepts,strategiesandmethods.(TechnicalPaperNo. 17).TheHague,The Netherlands,IRC, pp.89-108.

WHO (1993a). Improvingwaterandsanitationhygienebehavioursfor thereductionof diarrhoealdisease.Thereportof an informal consultation,Geneva,18-20May 1992. Geneva,Switzerland,WHO.

WHO (1993b).Working towardsbetterhygieneandbetterhealthin theabsenceof improvedfacilities.NewDelhi, India, WHOSouthandEastAsianRegionalOffice.

WHO (1994).SchoolsanitationandhygieneeducationinLatin America.Cali, Colombia,PAHO,WHO andIRC/CINARA.

Williamson,J. (1983).Towardscommunity-manageddrinkingwatersystemsin Nepal.Waterlines,Vol. 2 (2), pp. 8-13.

Wijk, C.van (1980).Theacceptanceof watersuppliesby usersin developingcountries(inDutch). H2O, 13 (24),pp. 599-602.

Wijk, C.van (1981).Participationandeducationincommunitywatersupplyandsanitationprogrammes.(TechnicalPaperseriesno 12).TheHague,TheNetherlands,IRC.

Wijk, C.van (1985). Participationof womeninwatersupplyandsanitation:rolesand realities.(TechnicalPaperseriesno 22).TheHague,TheNetherlands,IRC.

World Bank. (1993).World DevelopmentReport.Washington,D.C., USA, World Bank.

Yacoob,May. (1989). TheUSAID/CAREcommunitywaterprojectin Haiti: anassessmentof usereducation.(WASH Field report,no 258).Arlington,WaterandSanitationfor healthproject.

Yoder, P.S.et al. (1993.) Ethnomedicalresearchfordevelopmentalpurposes:examplesfromNigeriaandZaire. In Seidel,R.ed.Notesfrom the fieldin communicationfor child survival.Washington,D.C.,USA, AcademyforEducationalDevelopment.

Zimicki, S. (1993).Understandingthediarrheaproblemin thePhilippines:Researchasabasisfor messagedesign.In: Seidel,R. ed.Notesfromthe field in communicationfor child survival.Washington,D.C., USA,AcademyforEducationalDevelopment.


ANNEX 1

Transmission patterns and preventive measuresfor water and sanitation-related diseasesSource: Boot & Cairncross, 1993:10-11

domestic hygiene water hygiene wastewaterand animal and food safe water disposaF

management hygiene consumption and drainageInfection Transmission pattern safe human personal

excretadisposal hygiene

Vadous type ofdiarrhoeas,dysenteries, typhoidand paratyphoid

From human to mouth (faecal-oral) via multiple routes offaecally contaminated water, fingers and hands, food, soil andsurfaces (see Figure 1). Animal faeces (e.g. from pigs andchickens) may also contain diarrhoeal disease organisms.

U U U • U

Roundworm(Ascariasis),Whipworm(Trichuriasis)

From faecesto mouth: Worm eggs in humarffaeces have toreach soil to develop into an infective stage before ingestedthrough raw food, dirty hands and playingwith things that havebeen in contact with infected soil. Soil on feet and shoes cantransport eggs long distances. Animals eating human faecespass on the eggs in their own faeces,

U • • •

Hookworm From faecesto skin (especially feet): Worm eggs in the faeceshave to reach moist soil, where they hatch into larvae whichenter the skin ofpeople’s feet.

U U

Beefand porktapeworms

From faecesto animals to humans: Worm eggs in human faecesare ingested by a cow or pig where they developinto infectivecysts in the animal’s muscles. Transmission occurs when a personeats raw or insufficiently cooked meat.

• U

Schistosomiasis(bilharzia)

From faeces or urine to skin: Worm eggs in human faeces orurine have to reach water where they hatch and enter snails. Inthe snails they develop and are passed on as free swimming“cercariae” which penetrate the skin when people come intocontact with infested waters. In theAsian version of theinfection, animal faeces also contain eggs.

• U I

Guinea worm From skin to mouth:The worm discharges larvae from a woundin a person’s leg while in water. These larvae are swallowed bytiny “water fleas” (cyclops), and people are infected when theydrinkthis contaminated water.

U

Scabies, ringworm,yaws

From skin toskin: Both through direct skin contact and throughsharing of clothes, bedclothes and towels.

U U

Trachoma, conjunctivis From eyes toeyes: Both direct contact with the discharge froman infectedeye and through contact with articles soiled byadischarge, such as towels, bedding, clothing,wash basins,washing water. Flies may also act as transmission agents.

U I

Louse-born typhus,Louse-born relapsingfever

From person to person: Through bites of body lice which travelfrom person to person direct and through sharing clothes andbedclothes, particularlywhen underwear is not regularlywashed.

U U

.

Malaria, yellow fever,dengue

From person to person throughthe bite of an infected mosquito.The mosquito breedsin standing water.

U •

Bancroftian filariasis From person to person through numerous bites by infectedmosquitoes. The mosquitoes breed in dirty water.

U U:

U


32 Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms ofChange

ANNEX 2

Motivating improved hygiene: An annotatedbibliography with keywords on hygiene behaviors,motivating factors and country1. Ahmed,N.U. etal. (1993).A longitudinalstudyof the impactof behavioralchangein-terventionon cleanliness,diarrhoea!mor-bidity andgrowth of chi!drenin ruralBangladesh.SocialScienceandMedicine,Vol. 37 (2),pp. 159-171.

During participatorydiscussionsmothersdiscussedtheir hygienepractices,sanitaryconditions,beliefsregardingcausesofdiarrhoeaandpossibletreatments.Thisresultedin twentytargetchanges,likesweepingfloors moreoften. Theyweretriedby projectworkersandvolunteermothersofthetargetgroup.Applicableadvicewastranslatedinto simplemessages,resemblingpopularfolksongs,popularproverbsandpoems.Local leaderssupportedthecam-paign.Observationsshowedthat theinter-ventionsitehadsubstantiallyhighercleanli-nessscores,alower diarrhoealmorbidityandbettergrowthstatusof infants comparedtothoseof thecontrolgroup.

Handwashing,sanitarypractices,foodhygiene;understanding,influence(from local leaders),enablingfactors(brooms);Bangladesh.

2. Aini, Fitri (1991). Radio show spreads thewordsaboutwater,healthandsanitationtoislandsin Indonesia.PaperpresentedattheGlobalAssemblyon WomenandtheEnvi-ronment,Miami, Florida,4-8November1991.

Lackof goodexcretaandgarbagedisposalpolluteswatersourcesandis acommoncauseof water-relateddiseasesin Indonesia.A radio programmefor farmers’womenusesadialoguebetweentwo farmwomentopromotepracticalunderstandingandsanitaryself-improvements.Broadcastsareatasuitabletime (5.30a.m.)andusesimplelanguage.Thescenario’sarebasedonmeetingsandinterviewswith thetarget

group.In aquestionnairesurveylistenersreportedbetterknowledgeandpractices,butthereareno before/afterobservationstoconfirm theseresults.

Excretadisposal,wastedisposal,wateruse,hygienepractices;understanding,peerinflu-ence,enablingfactors(easyaccessto relevantinformation);Indonesia

3. Alam, N. et al. (1989). Mothers’ personalanddomestichygieneanddiarrhoeainci-dencein youngchildrenin ruralBangladesh.InternationalJournalof Epidemiology,vol.18 (1),pp.242-247.

A combinationof hygienepracticesde-creasedyearlydiarrhoeaincidencein chil-drenby morethan40% comparedto chil-drenliving in householdswherenoneoronlyoneof thesepracticeswasobservedin tworuralareasin Bangladesh.The observedpracticesincludeduseof handpumpwaterfor drinking andwashing,removalofchildren’sfaecesfrom theyard,andmaternalhandwashingbeforehandlingof food andafterdefecaetionof selfandchild.Moremothersliving in theinterventionarea,wherehandpumpswere installedandhy-gienemessageswerespreadobservedall fourhygienepracticesthanmothersliving in acontrol area.

Handwashing,wateruse,domestichygiene;understanding,facilitation; Bangladesh

4. Albihn, M. eta!. (1982). Integratingwomenasameansof ruraldevelopment.Acasestudyof theSwedishCADU project.Stockholm,SIDA.

The projectcoveredirrigation,improvementof agriculturalpracticesandwatersupply. Itconcentratedon maleparticipation.Womengot classeson health,hygieneandhome


economics.Over8000womenattended.Half 7. Baranowski,T. (1992-1993).Beliefs asmo-appliednewpractices,but nonefelt abletoinfluencehygienepracticesof otherhouse-holdmembers.Wherewomenparticipatedin siting, wellswereplacedsatisfactorily,butafterawhile 60% couldnot beusedfor lackof maintenance.

Domestichygiene,watersourceuse;influence,enablingfactors(gender);Ethiopia.

5. Audibert, M. (1993). Social and epidemio-logicalaspectsof guinea-wormcontrol.So-cial ScienceandMedicine,Vol. 36 (4), pp.463-474.

Comparisonof differentstrategiesto eradi-categuinea-wormin ninevillagesin Malishowsthat provisionof safewatersources

canbeeffective,particularlyin thoseregionswherewater isveryscarce.Hygieneeduca-tion to encouragefiltering of waterwasprimarily targetedat men,who weresup-

posedto disseminatetheinformationtotheirwives.Therequiredlong-lasting

modificationof behaviourdid only comethroughunderfavourableconditions,like astrongsocialcohesionor co-ordinatedgroup-actionand/orwhenguinea-wormcontrol is apopulationpriority goal.

Watersourceimprovement,filtering; facilita-tion, understanding,influence;Mali

6. Aziz, K.M.A. etal. (1990). Water supply,sanitationandhygieneeducation.Reportofahealthimpactstudyin Mirzapur,Bangladesh.Waterandsanitationreportse-ries1. WashingtonD.C.,UNDP/WorldBank

Thisstudyevaluatesthe successof an inte-gratedpackageof interventionsin a ruralareain Bangladesh.Theseinterventionsincluded:handpumpwatersuppliesat ashortdistancefrom households,pitlatrinesfor eachhouseholdandan elaboratehygieneeducationprogramme.In theinterventionareatherewassignificantly lessdiarrhoeaofall kindsin all seasonsin the four yearsoffollow-up thanin thecontrolarea.

Wateruse,pitlatrines;facilitation, understand-ing,enablingfactors;Bangladesh

tivationalinfluencesatstagesin behaviourchange.Int’l Quarterlyof CommunityHealtheducation,Vol 13 (1),pp.3-29.

Five theoriesof behaviourchangearere-viewedto identify motivational(belief)factorsin promotinghealthbehaviourchangesat eachof six stagesof thebehaviourchangeprocess:precontemplation,contem-plation, decision,training, initition and

maintenance.

Understanding,facilitation, influence,enablingfactors;general

8. Boot,M.T. (1991).Juststir gently.Thewayto mix hygieneeducation with watersupply and sanitation. TP29. The Hague,IRC.

Ch. 2 and3 discusshowto promotehygienebehaviour,Ch. 2 looksatit from a‘dailyroutine’pointofview. Introducingnewwaterandsanitationfacilities formsanexcellentopportunityto discusshygienebehaviour.Hygienepromotionis morelikelyto besuccessfulwhenusergroupsarein-volvedin selectingappropriatetechnicalsolutions,whenit buildsuponlocal cultureandpriorities andis supportedby respectedcommunitymembers,projectstaffandauthorities.Ch. 3 providesa shorttheoreticalbackground.To plana soundhealtheduca-tion strategyoneshouldfirst selecta ‘felt’healthproblem,thenidentifythelinked

behavioursandcategorizetheseinto predis-posing,enablingandreinforcingfactors.

Watersupplyandsanitation;facilitation,understanding,influence(from leaders),enablingfactors;general

9. Boot, M. T. &S. Cairncross.(1993).ActionsspeakThestudyofhygienebehaviourinwaterand sanitationprojects.London, LondonSchoolofHygiene& The Hague,IRC.

The studyof hygienebehaviouris importantto improvetheeffectivenessof watersupply,sanitationandhygieneeducationpro-grammes.Theavailableliteratureis reviewedto specifylinks betweenhumanbehaviourandthe transmissionofwaterandsanitationrelateddiseases.Theauthorsconcludethat


— in general— reductionof thesediseases

canonly beachievedby a combinationofbetterhygienebehaviours.Culturalconceptsof purity andcleanliness,perceptionsabouttransmissionrisksandsocio-economicanddemographiccircumstanceshaveto betakeninto accountwhenstudyingbehaviours.Differentmethodsto studybehaviour—

observationsandinterviews— arediscussedextensively,as well ashowto designandorganizesucha study.

Handwashing,excretadisposal,bathingandwashing,waterandfoodhygiene,soilcontact,animalcontact,fly control; transmissionrisks,knowledge,understanding;general.

10. Booth, E.M. (1992). Selecting and priori-tizing targetbehavioursin publichealthpro-grams.WHO, informalconsultation.

Therearetwo majorcriteria for the selectionandprioritization of targetbehaviours:potentialimpacton thehealthproblemandamenabilityto change.Theserequireanin-depthunderstandingofthetargetaudience.The papergivesa list of stepsto perform—

from analyzingthe healthpracticeto select-ing andprioritizing behaviours.Thebehav-ioural analysisscaleis a tool to useto seewhichbehaviourshavethemostpotential.Finally a case-studyfroma ruralvillage nearGuatamala-cityis given to illustrate the stepsto taketo stimulatecorrecthandwashingbymothers.

Hygienebehaviour,handwashing,transmissionrisks; facilition, understanding;Guatamala

11.Booth,E.M. &E. Hurtado.(1992).Theapplication of public health communicationin waterandsanitationprograms.WHO, In-formal consultation.

Introducinga simpledeviceto reducetheamountof waterneededfor handwashing,combinedwithhome-visitsto spreadkey-knowledgeconcerningcorrecthandwashingto makechildrenhealthyreduceddiarrhoeal

morbiditysignificantlyin the interventiongroup in a village in Guatamala.Fathersand

childrengotadditionalmessagesto reinforcethedesiredbehaviours.No mass-mediawereusednor meetingsat public placesheldtoavoidcontaminationof thecontrolgroup.

Theauthorsstressthe needto includetimeto ‘maintain’ newbehaviours.

Handwashing;facilitation, understanding;Guatamala.

12.Brieger,W.R. Ct al. (1990-1991). Moni-toring useofmonofilamentnylonwaterfiltersfor guinea-wormcontrol in aru-ral NigerianCommunity.Int’l QuarterlyofCommunityHealthEducation,Vol. 11(1),pp. 5-18.

Monitoring of filter-useto preventguinea-wormin a ruralcommunityin Nigeriahighlightedthefollowing problems.Despitehygieneeducationandavailabilityatlow costof filters onlyaboutonethird of thepopula-tionboughtfilters,while othersobjectedthatfilters couldnot preventthedisease,costtoomuchor wereinferior to othersolutions.Thosewho did buydid not usefilters always(esp.nearthefarm), did not cleanthemregularlyor usedthemupsidedown.Mostpeopledid not changefilters afteroneyearusewhentiny holesappeared.

Waterfiltering; understanding,enablingfactors(filters); Nigeria.

13.Burgers,L. etal. (1988).Hygieneeduca-tion in water supply and sanitation pro-grainmes.TP27. TheHague,IRC.

Behaviouralchangesareinfluencedby anumberof factorsotherthanhealthconsid-erations— affordability, makinglife easierandsolvingafelt problem.Incentivestochangebehaviouraretimegains,economicgainsor increasedstatus.Rewardsandpunishmentsdo notususallyhavea long-lasting impact.Hygieneeducationpro-grammesaremoresuccessfulwhentheybuild on existingculturalpracticesandpracticalunderstandingof diseasetransmis-sionandwhensupportedbyrespectedkey-personsin thecommunity.Thebookfurthergives an overviewofthreeeducationalapproachesto hygieneeducation:didactic,promotionalandparticipatoryandtheirrespectiveadvantagesanddisadvantages.

Watersupplyandsanitation;facilitation,understanding,influence(fromkeypersons),enablingfactors;general


14. Cairncross, S. &J. Cliff. (1987).Wateruseandhealthin Mueda,Mozambique.Transactionsof theRoyal Society of Tropi-cal Medicine and Hygiene, 81, pp. 5 1-54.

Womenliving on average300metersfrom astandpipeused2—3 timesmorewaterthanotherwomen.Theextrawaterandsavedtimeareusedfor bathing,clotheswashing,food preparationandfrequentwashingofchildren.Trachomaincidencewashalfthatof aneighbouringvillage withoutpipedwater.

Clotheswashing,bathing;facilitation;Mozambique.

15.Clemens,J.D.& B.F. Stanton.(1987).Aneducational intervention for altering waterand sanitation behaviours to reduce child-hooddiarrhoeain urbanBangladeshI andII. mt. Journal of Epidemiology Vol 125 (2),pp. 284-301.

Researchin urbanBangladeshidentifiedthreewatersanitationbehavioursthatdifferentiatedgroupsof families with alowandhighincidenceof childhooddiarrhoea:

1. Handwashingof mothersbeforethepreparationof food

2. Defecaetionof the childrenin thelivingareaofthe family

3. Childrenplacinggarbageor wasteprod-uctsin their mouth.

Basedupon theseassociationsan educationalinterventionwas designed,whichconsistedof a few simplemessageswhoseprescribedbehavioursalreadyoccurredin anumberofhouseholdsin thecommunity.After theintervention,moremotherswashedtheirhandsbeforepreparingfood thanin acontrolarea.Theincidenceofdiarrhoeaexperiencedbychildrenreducedsubstan-tially. However,no improvementwasobservedfor defecaetionandwastedisposalpractices.

Handwashing,defecaetionofchildren, wastedisposalpractices,facilitation, understanding;Bangladesh

16. Derslice, J. van& J. Briscoe.(1991). Allcoliformsarenot created equal: a compari-sonof theeffectsofwatersourceandin-housecontaminationon infantilediarrhoeadisease.Universityof NorthCarolina.

Watersourcecontaminationposesa muchmoreseriousrisk of diarrhoeathanin-housecontaminationofwater,as shownby astudywith 2355 Filipino infants.The first intro-ducesnewpathogensin thefamily, whereasfamilymembersarelikely to developsomelevel of immunityto pathogenscommonlyencounteredin the household.Moreover,inthesecondcase,person-to-personcontactorfood contaminationaremorelikely transmis-sionroutes.

Waterhygiene(water sourcequalityandwaterstorage);diarrhoealdiseasetransmissionroutes;Philippines.

17. DiPreteBrown,L. & E. Hurtado.(1992).Development of a behaviour-monitoringsystemfor thehealtheducationcomponentof the rural water and health project —

CAREGuatamala.Washfield reportno 364.WashingtonD.C.,Wash.

A simplemonitoringsystemfor assessmentof CARE Guatamala’swater,sanitationandhygieneeducationprogrammewas developedby theWashproject,usingapproximately40indicators.Theseincludemeasuresconcern-ing healthimpacts(children’sdiarrhoea),mother’sknowledge(ORT) andhealth

behaviours(diarrhoeamanagement,personalanddomestichygiene).

Personalanddomestichygiene;practices,knowledge;Guatamala.

18. Edungbola, L. et al. (1988). The impact ofUNICEF-assisted rural water project on theprevalence of guinea-worm disease in Asa,Kware state, Nigeria. Am. J.Trop. Med.Hyg.39 (1),pp.79-88.

Provisionofhandpumpsandboreholes,combinedwith (minimal) healtheducationreducedguinea-wormprevalenceenor-mouslywithin threeyearsof interventionineightvillagesin Nigeria. In twelve othervii-lageswhereimprovedwatersourceswerelessfavourablysited,hadan inadequatewater

S


coverage,anunpleasantwatertaste,colororsmellor wereotherwisemalfunctioningthedeclineof thediseasewaslessdramatic.Thisdemonstratesthe importanceof a convenientplanninganddesignofwatersources.

Wateruse;facilitation, understanding;Nigeria

19. El Katsha, S. & S. Watts. (1992/93). Amultifaceted approach to health education: acasestudyfrom ruralEgypt. InternationalQuarterlyof CommunityHealthEducation,13 (2),pp. 139-149.

Nursesandteachersin two villagesweremosteffectivein influencinghygienepractices—waterstorage,infant feeding,handwashing,food preparation,latrinecleanlinessandhy-gienichandlingof dungcakesfor fuel. Mes-sagesfocusedon practicalunderstandingofhowhouseholdpracticescantransmitdisease.PublicServiceCandidates,conscribedby the

governmentfor oneyear’svoluntarywork,bestreachedilliterate womenat home.

Trainedfemalevillage leaderswereleasteffec-tive: highturnover,highsupportneed,lowoutreach.Thisisascribedto thelimitationstovoluntaryorganizationfrom Egyptianlaw.Enablingsfactorsweretime andhousing

space.

Waterstorage,infantfeeding,handwashing,foodpreparation,latrine hygieneand hygienichandlingofdungcakesforfuel;understanding,influence,enablingfactors;Egypt.

20.El-Katsha,S. &A. White. (1989).Women,water and sanitation: household wateruse intwo Egyptianvillages.WaterInternational,vol. 14 (3),pp. 103-111.

A surveyin two similar deltavillages revealedthat thebetterwaterandsanitationinfra-structureof onevillagedid not accountforbetterhealth.Hygienebehaviour,ratherthanservicelevels,hadthegreatestinfluence.Understandingof diseasetransmissionwasfragmentary.Facilitationandpopularbeliefsdetermineactions.Clotheswashingis in the

canals,becausethe water is softer,gives abetterlatherandno sullageweakensthehouses.Schistosomiasisis seenas a real

dangerbut thoughtto becausedonly byswimminganddrinking, notby standingin

thewater.

Clotheswashing;facilitation, understanding(lackof); Egypt.

21. Fukumoto, M. & R. del Aguila. (1989).Whydo motherswash their hands? in : Dia-logueon Diarrhoea,issue39,December1989, p.S.

In shantytownsnearLima, Peru,mothershavedifferenthandwashingpracticesaccord-ing to variouskindsof dirtyness,usingdifferent typesofsoapandwater.Sincewateris expensive,muchwaterin thehouseholdisreused.Understandingexistingpracticesandbeliefsallowsdesigninghealthinterventionsthatreinforceculturalbeliefsandpracticesandaremoreeffective.

Handwashing,beliefs, understanding,facilita-tion;Peru

22. Gilman,R.H. & P.Skillicorn (1985).Boil-ing of drinldngwater:canafuel scarcecom-munityaffordit? Bulletin oftheWorldHealthOrganization,Vol.63 (1), pp.157-163.

Theeconomicfeasiblityandthe healthimpactof boiling drinking waterarebothhighly questionable.A village studyinBangladeshdemonstratesthat, whencollect-ablefuel is limited, families in thelowestincomequartilewould haveto spend22% oftheiryearlyincomeon fuel. Moreovervillag-

ersseldomtaketheir drinkingwateronlyfromthe drinkingpot,but drawwaterfromvarious(polluted)sources.Theauthorsrecommendtheinstallationof handpumpsasamoreappropriatesolution.

Drinkingwater; enablingfactors(fuel);Bangladesh

23. Haggerty, P.A. (1991). Community basedhygieneeducationto reducediarrhoealdis-easein ruralZaire: Measurementof hygienebehaviourbeforeandafter theintervention.Paperpresentedattheworkshopon mea-surementofhygienebehaviour,Oxford,April 8-12, 1991.

A hygieneeducationinterventionin ruralZairewasbasedon four key-messages:handwashingbeforefood preparation,andeatingandafterdefecaetion,properdisposaloffaecesandsweepingofcompoundtwice


daily. It wasimplementedby femalecommu-nity volunteers,usingsongs,stories,etc.Comparedto acontrol group,in the inter-ventionareachildrensufferedfrom lessandshorterperiodsof diarrhoeaandobservedabovementionedhygienebehavioursim-proved.Interestingly,behaviouralchangewashighly associatedwith volunteerperfor-mance.

Handwashing,domesticandpersonalhygiene;understanding;Zaire

24. Han, Aung Myo &T. Hlaing. (1989).Prevention of diarrhoea and dysentery byhandwashing. Transactions of the Royal So-cietyof TropicalmedicineandHygiene,no.83,pp. 128-131.

Giving motherssoapto washhandsbeforepreparingandeatingmainmealsandafterdefecaetionreduceddiarrhoeaepisodesintheir under5 yearoldchildren,comparedtoacontrolgroup.Dysenteryincidencesdecreasedless.

Theauthorsstatethatalastingpositivebehaviourchangerequiresbothculturallyappropriateeducationalprogrammesandreadilyandcheaplyavailablesoap.

Handwashing;understanding,enablingfactors(soap);Burma.

25.Henry, F.J.& Z. Rahim.(1990).Trans-missionofdiarrhoeain two crowdedareaswith differentsanitaryfacilitiesin Dhaka,Bangladesh. Journal of Tropical Medicineand Hygiene, 93, pp. 121-126.

In two denselypopulatedareasinBangladesh137 childrenwerestudiedtocomparetheimportanceof contaminatedhandsanddrinkingwaterin the transmis-sionof diarrhoea.In bothareastherewasasignificantcorrelationof contaminatedhandsanddiarrhoeaincidence.No correla-

tionwasfoundbetweenwatercontamina-tion anddiarrhoealincidence.This relation-shipstronglysupportsthepromotionofhandwashingas amethodof controllingdiarrhoealdiseasesand,by implication,thegreaterimportanceof waterquantitycom-paredto quality.

Handwashing;facilitation, diseasetransmissionroutes;Bangladesh

26. Hoque,B.A. & A. Briend.(1991).A com-parisonoflocalhandwashingagentsinBangladesh.Journalof TropicalMedicineandHygiene,vol. 94,no. i, pp. 61-64.

For handwashingtraditionalagentsareaseffectiveassoap.Theauthorscountedfaecalcoliforms from fingertip rinsesin agroupof20 women.Onfive consecutivedays,thewomenwashedhandswith soap,ashes,mud,wateronly or not atall. No washingled tocontaminatedfingersfor 14 women.Washingwith wateronlymadeno difference.Washingwith mud,ashesor soapeffectivelyremovedfaecalbacteria.As handwashingwith tradi-tional agentsis not promoted,thispracticeisnot widespread(15%usemud)andmanywomenarenot awareof its benefits.

Handwashing;facilitation, understanding,enablingfactors(availability, cost),Bangladesh.

27. Hubley, J. (1993). Communicatinghealth. An action guide to health educationand health promotion. London, TheMacmifian Press LTD.

Thisbookexploresthe role of communica-tion in improvingpeople’shealthanddis-cussesstrategiesfor healtheducation,healthpromotionandempowermentof familiesandcommunitiesto takeactionon healthissues.Practicalguidelinesaregivenon howto carry

out effectivecommunicationwith families,communitiesandthroughschools,healthservicesandthemassmedia.Ch.2 discussesfactorsthat influencehealthbehaviours;therole culture,socialchangeandeconomicfactorsplay in determiningbehavioursandhowthiscan beusedto planhealtheducationandhealthpromotionprogrammes.Ch. 3treatsbasicsof thecommunicationprocess,providesguidelinesfor successfulcommuni-cationandexploresthemain characteristicsof arangeof communicationmethods.

Hygienebehaviour(general);beliefs, under-standing,influence,enablingfactors;general


28. Jaeger-Burns, J. & F.Mattson.(1989).Evaluationoftheenvironmentalcomponentof thecommunity-basedintegratedhealthandnutritionprojectin Guatemala.(WASHFieldReportno.251).Arlington, U.S.A.,WASH.

In four yearsthe projecthelpedconstruct168villagewatersystemsand13,500latrines.Evaluationshowedreasonablefunctioninganduse,but homestorageofwater,childsanitationandto alesserextentlatrinehygienewereunsatisfactory.The authorsconcludethatfacilitation improveshygiene,but thathygieneeducationandadaptationoflatrinedesignarerequired.

Waterstorage,wateruse,latrine use, latrinehygiene;facilitation; Guatemala.

29. Kanki, B. et al. (1991). Measuring hygienebehaviours: experiences of a comprehensiveapproach in Burkina Faso. A contributiontotheworkshopon measuringhygienebehav-iours, Queen’s College, Oxford, 8-12 April1991.

Differentstudytechniques— discussiongroups,questionnairesandobservations—usedin astudyof child healthin a town inBurkinaFasohighlightedvariouselementsofhygienebehaviours.Differentationwasmadebetweenthe ideal— whatmothers’realbelieftell themthattheyshoulddo; the image—

theimagemotherschooseto presentto fieldworkers;andtheactual— whatmothers

actuallydo.

Domestichygiene;practices,beliefs;researchtechniques;BurkinaFaso

30. Laike, S.A. (1992).Thequalityof drink-ing water in Gondar, Ethiopia: influence ofdemography, socio-economic factors, envi-ronmental hygiene and health education.

~ (Technical Publication no. 90) Tampere,Tampere Technical University.

Testfor bacteriologicaldensityatthesource,duringwatertransportandin householdstoragecontainersshowedhigh feacalcon-taminationat all threelocations.Selectedhouseholdsweregivenhygieneeducationcombinedwith the introductionofa low-costwater treatmentsystemandsimpletech-

niquesfor saferwaterstoragein the home.Thisresultedin considerablelowercountsforbacteriologicalcontaminationthanbeforetheinterventionandin comparisonwith thecontrolgroup.

Waterfiltering~waterstorage;knowledge,understanding,enablingfactors(larger storagecontainersandsimplegravelandsandfiltrationsystems);Ethiopia

31.McCauley,A.P.etal. (1990).Changingwaterusepatternsin awaterpoorarea:les-sonsfor atrachomainterventionproject.So-cial ScienceandMedicine,Vol. 31(11),pp.1233-1238.

Mothersin thisdry areadid not washchildren’sfacesfrequentlybecausetheyprefereconomicusesof waterandtimeandbeliefthatfacewashingdemandsmuchwater.Otherinfluenc-ing factorswereneighbours’examplesandhusbands’attitudes.An experimentwith womenandmenpractisingfacewashingdemonstratedthatwith onelitre theformermanaged30-35faces,thelatter12. Thefindingsareusedfor aprojectto changefacewashingpracticesin thewholecommunityandmeasureimpactontrachoma.

Facewashing;understanding,influence,en-ablingfactors;Tanzania

32. Mc Cauley,A.P. Ct al. (1992). Householddecisions anomg the Gogo-people of Tanza-nia: determining the roles of men, womenand the community in implementing a tra-choma prevention program. Social Scienceand Medicine, Vol. 34 (7), pp 817-824.

A studyin preparationof atrachomapreven-tion programmefound thatmotherswerereluctantto washchildren’sfacesmoreoften.Fetchingtheperceivedextraamountof waterwould taketoo muchtime not spendon moreimportantdutieslike growingfood, for whichtheywould becritizedby their husbandsandmothers-in-law.Mothersdid not believewashingwould cureall eye-problems.Besideschildrenwouldbe re-infectedby theirplay-mates.Thereforethe healthinterventioncampaignaddressedall communitymembersto getsupportfor the mothersfrom theirfamily membersandto ensureasmany


childrenfacesto bewashedaspossible.Ademonstrationshowedthatin factfacewashingrequireslittle water.

Face-washing;knowledge;influence(fromhusbandsandmother-in-law),enablingfactors(time, water); Tanzania

33. Mukherjee,N. (1990)People,waterandsanitation:whattheyknow,believeanddoin ruralIndia. NewDelhi, NationalDrink-ing WaterMission.

A KAP studyconcerningwater andsanita-

tion wascarriedout in 22 districtsin 8 statesin India.Althoughonly 4-15%of inter-viewedpeoplehaveaprivatelatrine,around86% mentionedprivacyandconvenienceasadvantagesofhavingone.Healthhazardswerenot frequentlyconsidered.Children’sfaecesarebelievedharmless.Significantly,concerningwater,womenmentionedthecookingqualityasareasonto chooseacertainsource.Womenweremorewillingthanmento payandrepair(new) installa-tions.

Wateruse,latrine use;beliefs,practices,facilitation, understanding;India.

34. Narayan,D. (1989). Indonesia: evaluat-ing communitymanagement.(TechnicalSe-ries), NewYork, PROWWESS/UNDP.

Usingparticipatorymethodsandlocalorganizations,4 villageswereassistedtoimprove theirwater supplyandhygiene.After 14 months,65%ofthe householdsusedimprovedwatersources,andwateruseincreasedto 10 l/c/d, notcountingwaterusedatthe source.Observedcleanlinessofcontainersandwaterdecreased,but maybedueto strongersubjectivenormsof thevillage evaluatorsandshowstheneedforobjectivemeasurementcriteria.Observedsafekeepingofwaterdippersimproved.

Watersources,waterconsumption,waterstorage;facilitation; understanding;Indonesia.

35. Pinfold, J. (1990).Faecalcontaminationof waterandfingertip-rinsesas amethodforevaluatingtheeffect oflow-costwatersupplyandsanitationactivitieson faecal-oraldis-easetransmission:II. A hygieneinterventionstudyin ruralnortheastThailand.Epidemi-ology andInfection,no 105,pp. 377-389.

Hygieneeducationcombinedwith provisionof aplasticcontainerwith tap wasmoresuccessfulin improvinghand-anddishwashingpracticesthanhealthmessagesalone.Indicatorsofcompliancewerethedirect observationof soakingdishesandthepresenceoffaecalstreptococcifromfingertiprinses.

Hand-anddishwashing;facilitation, under-standing;Thailand.

36. Sandhu,S.K.etal. (1977).Adoptionofmodernhealthandfamily planningpracticesin aruralcommunityin India. InternationalJournalof Hygieneeducation,20,(4), pp.240-247.

Contactswith healthstaffmadeasignificantdifferencein adoptingfive newhealthprac-ticesby asampleof 170women.Construc-tionof latrineswaslowest(12%), althoughknowledgewashigh.Theauthorsascribethisto healthbeingnot amajor reasonforinstallinga latrineandthepresenceof anacceptedalternative(sufficient nearbyfieldswith vegetation).

Latrineconstruction;influence(from healthstaff);India

37. Simpson-Hebert, M. (1993) Sanitation:the unmet challenge. Newissues paper forthe water supply and sanitation collaborativecouncil. Rabat meeting. CWSunit/WHO.

Byprioritizing certainkeyhygienemessages,improving theeducationaltechniquesofpromotersandinvolving womenandcom-munitiesmore,demandcanbecreatedandsanitationcanbecomemoresuccessful.Innovativeapproachesshouldbe sharedan4policy makersconvincedof the economicandhealthimplicationsof sanitation.

Latrineuse,handwashing,domestichygiene;promotion,policymaking;general


38.Smith, G.D. (1993).Cultural construc-tion of diarrhoeain Nicaragua.SocialSci-enceandMedicine,Vol 36 (12),pp. 1613-1624.

Interviewsandgroupdiscussionswith 70mothersin a ruralareain Nicaraguarevealedthatmostmothersdifferentiatedbetween9typesof childhooddiarrhoeaandsoughttreatmentaccordingto thetype.Dismissionof traditionalbeliefsandpracticesby thehealthcentresandtheirstrongfocuson ORSandimprovedhygienepromotionseemstoresult in treatingonlycertaintypesofdiarrhoeain healthcentersandmayalienatepeoplefrom official healthpromotionmessages.Moreover,onemissesthe chanceof co-operationwith traditionalhealerswhocould becomeimportantagentsin thepromotionof ORS.

Beliefs, influence(traditional healers);Nicara-gua.

39. Soeripto, N. (1989). Impact of environ-mentalimprovementon thepatternof soil-transmittedhelminthinfections:theJogyakartacase:paperpresentedattheAsian ParasiteControl! Family PlanningConference,11th ParasitologistsMeeting,Jakarta,Indonesia,16-20October1989.

Masstreatmentof worms,constructionofnewwells andlatrinesandhygieneeducationthroughwomen,local leadersandhealthcadresreducedprevalenceof whip- andhookwormin avillage in Indonesia.Latrinecoverageincreased40%,latrinehygiene64%andreporteduse70%.This combinationofinterventionsprovedmoreeffectivethanthosethatusedonly masstreatmentor incombinationwith healtheducationandwellsconstruction.

Latrines,useand hygiene;facilitation, under-standing,influence(local leaders);Indonesia.

40. Spector, P. et al. (1971). Communicationmediaandmotivationin theadoptionofnewpractices,anexperimentin ruralEcua-dor.HumanOrganization,30 (1), pp. 39-46.

Latrine installationandadoptionof 3 otherhealthpracticesweresignificantlygreaterintwo townswith gender-specificmedia

campaignsthanin onecontrol town. Menweremotivatedto build latrinesby holdingmeetingsin town with audio-visualmediaandstimulatingthemto form teamsformutualhelpin construction.Womenweremotivatedto adopthealthpracticesathomeby providingthemwith radiosandreachingthemwith specialhealtheducationpro-grammes.

Latrine construction;knowledge;influence(from malepeers);enablingfactors(radios,labour); Ecuador

41. Srinivasan, L. (1990). Tools for commu-nity participation: a manual for trainingtrainersin participatorytechniques.NewYork, PROWWESS/UNDP.

Thismanualintendsto stimulatestaffofwaterandsanitationprojectsto usepartici-patorymethodsin their programmes.Themanualoffers alargenumberof activitiesandexercisesto help localgroupsdeveloptheir cohesivenessandco-operationandtoanalyselocal conditions,beliefsandpractices.Local groupsarestimulatedto planandimplementproblemsolving actionsandbecomecreativein finding answersto atfirstinsolubleproblems.

Waterandsanitation;participatoryap-proaches;general.

42. Srinivasan,L. (1992).Optionsfor educa-tors. A monographfor decisionmakerson al-ternativeparticipatorystrategies.NewYork,PACT/CDS.

PartI of thisbook reviewsthreeeducationalstrategiesfor workingwith disadvantagedcommunities,the didacticmode,educationfor societalchangeandthegrowth centerededucationalapproach.PartII suggestsconcretewaysto buildparticipatorymethodsinto thetrainingof staffandvolunteers.PartIII showswaysofinvolving seniorstaffintoparticipatoryactivities,to demonstrateitsvalue.

Educationalapproaches;general


43. Srivastava, P.K. (1969). Acceptance ofsanitary composting in rural areas. IndianJournal of Public Health, 13 (1), pp. 30-35.

Perceivedeconomicbenefitmotivated55 outof 77 householdsto compostcattleandhouseholdwasteinto pits,aftertheygotinformationandinfluencefrom massmedia,demonstrations,massandgroupmeetingsandpositiveaccountsfrom local leaders.Healthbenefitswererecognized,butnotmentionedas important.Enablingfactorswere: largelandholdingsandmanycattle—

somorewasteandgreaterbenefits— andsmallwalkingdistanceto refusepit.

Pit latrines (manurepits, compostpits);understanding,influence(from leaders,peers),enablingfactors, India

44. Steuart, G. et al. (1962). Sanitationchanges in an African community: a study ofprimary group education. Health EducationJournal,20 (3), pp. 133-140

In apen-urbancommunity,healthworkersidentifiedleadersin informalwomen’snetworks.Eachworkertrained24 leadersonsafeexcretaandgarbagedisposal,fly preven-tion andkilling andfood andwaterprotec-tion.Homeobservationsestablishedabaseline.Theleadersheldmeetingswithfriends,discussingdiseasetransmissionandhygienepracticesandreaching62%of the1765families. A poststudyshowedsignifi-cantchangeon all six conditionsas com-paredto acontrolareawhich hadtheusualprogramme(massmediainformationandpromotionof improvementsat communitylevel throughworking withprominentcommunityleaders).

Excretadisposal,wastedisposal,fly control,foodhygiene,waterhygiene;understanding,peerinfluence;SouthAfrica.

45.Toit, F.P.du (1980).A designfor ruralvillagewaterpointsin Zimbabwe.Proceed-ingsof theseminaron watersupplyanddrainageservicesin developingcountries.Pretoria,CSIR,NationalBuildingResearchInstitute.

Siting the waterpointwherethewomenwantedit (outsidethevillage for ameeting

placeandwith landfor avegetablegarden\andadaptingthe designto their needs(facili-tiesfor laundryandchild-bathing)increase~dwateruseto 60 1/c/d. Wastewater fromwashing/bathingwas usedto waterthecommunalvegetablegarden.Thewomenalsomanagedmaintenanceandhygiene.At thetimeof reportthesystem,managedby thewomen,workedreliably for 7 years.

Waterconsumption,water reuse,drainage;facilitation; enablingfactors(usermanage-ment);Zimbabwe

46. Uddin Khan, M. (1982). Interruption ofShigellosisby handwashing. Transactions oftheRoyalSocietyof TropicalMedidneandHygiene,76 (2),pp. 164-168.

Healthworkersgavefamilieswitha con-firmed caseof shigellosissoap,waterstoragepotsandeducationon handwashingandmonitoredhandwashingbehaviour.Trans-missionof shigellosiswassignificantly lowerin thisgroupthanin acontrol group(10%versus32%).

Ijandwashing;facilitation, influence,control(from healthstaff);Bangladesh

47. UNDP/WorldBank(1990)Ruralsanita-tion in Lesotho.WashingtonD.C. UNDP/World BankWaterandSanitationProgramandPROWWESS.

Village healthworkersandinterestedvifiagersformedparticipatorylearninggroupstoimproveliving conditions.Storytelling,games,dramaticpresentationsandcommu-nity surveyandmappingemphasizedtherelationshipbetweengoodhealthandspecifichygienepractices.Communityleaderstookpartin workshops,volunteers(manyof themwomen)weretrainedasbuildersanddemon-strationlatrineswerebuild atpublicplacesinthevillage. By showingtheadvantagesofeffectiveuseofimprovedsanitation,latrinesbecamea priority andactualhygienepracticeschanged.Householdspaythefull costsofimprovedlatrines.A healthimpactevaluationin oneareashowedasignificantdeclinein theincidenceof diarrhoea.

Latrineuse,handwashing,domestichygiene;facilitation, understanding~influence;Lesotho


48. United Republic of Tanzania, Danidaand CCKK. (1987).Implementation of wa-ter maste plans for Iringa, RuvumaandMbeya Regions: water consumption in sixvillages.

Theinstallationof apipedwatersystemwithuserinvolvementin taplocationof thestand-pipesbroughtconsiderablyhigherwater

consumptionthantheaverageamountscollectedfromtraditionalsourcesbeforetheproject.

Waterconsumption;facilitation; Tanzania

49. WHO/CWS/CDD.(1993). Improvingwaterandsanitationbehavioursfor there-ductionofdiarrhoealdisease.Geneva,WHO.

Saferdisposalof faeces,handwashingafterdefecaetionandbeforepreparingfood andeatingandmaintainingdrinkingwaterfreefrom contaminationarethreekeyhygienemessagesto bepromotedto reducediar-rhoea!morbidity. To promoteimprovedwaterandsanitationrelatedbehavioursthreeinnovativeandeffectiveapproachesarediscussed:public healthcommunications,

participatorymethodsandschoolhygieneeducation.

Transmissionrisks; educationalapproaches

50. Wilson, J. M. et al. (1991). Handwashingreduces diarrhoea episodes: a study inLombok, Indonesia. Transactions of theRoyalSocietyofTropicalMedicineandHy-giene,85, pp.819-821.

Sixty-fivemothersfrom avillage in Lombok,Indonesia,receivedsoapandsimplehealthmessageson causesof diarrhoea.Theseincludedsuggestionsto washhandsbeforepreparingandeatingfood andafterdefecaetionandwererepeatedfortnightly.Comparedto a controlgroup,diarrhoeaepisodesof childrenofthesemothersre-ducedby 80% duringthe periodof study.Whetherthecampaignhaslastingresultsremainsto beseen.

Handwashing;understanding,enablingfactors(soap);Indonesia

51.Yacoob,May. (1989).TheUSAID/CAREcommunitywaterprojectin Haiti: an assess-mentof usereducation.(WASH Fieldre-port,no 258).Arlingtthi, WaterandSanita-tion forhealthproject.

Local womenpromotorsorganizehealthdiscussionswith groupsof 10-15menandwomenin acommunitystandpipepro-grammein Haiti. Themesin thethreeweeklymeetingsarebasedon resultsof baselinesurveysandincludehandwashing,latrineuse,standposthygieneandcoveringwatervessels.Evaluationof thehealthimpactisplannedfor, but focusseson increasedknowledge.Theauthorrecommendsto lookfor handwashingmaterialsin cookingareasandnearlatrinesasindicatorsfor actualbehaviouralchange.

Handwashing,latrine use,waterhygiene;facilitation, understanding;Haiti

52. Zeitlyn, S.(1991)Measuring hygiene be-haviour:theimportanceof meaninganddefinition.Paperpresentedattheworkshopon measuringhygienebehaviours,Queen’sCollege,Oxford,8-12April 1991.

Handwashingistakenas anexampletoillustratethat for abehaviourto bemeasuredusefully, it mustbefound outwhy people

behaveastheydo— differenttypesandreasonsof handwashing— andwhichaspectsof thebehaviouraremostimportantto reducediseasetransmission— quantityofwaterused,typeof cleansingagent,actionofthe handsetc. To beableto modifybehav-iour it mustbe evaluatedwhich crucialaspectsarepracticallyapplicableineverydaylife.

Handwashing;practices,beliefs, researchmethods,Bangladesh


53.Zeitlyn, S. & F. Islam.(1991)Theuseofsoapandwaterin two Bangladeshicommu-nities:implicationsfor thetransmissionofdiarrhoea.Reviewofitifectiousdiseases1991; 13 (4),pp.259-264.

A studydonein two poorcommunitiesinBangladeshrevealedthatcleanlinessisviewedin asocio-religiouscontextofpurityversusimpurityandnot directlyrelatedtodiseases.Handwashingafterdefecaetionandbeforeeatingis doneby routinelypouringwateroverthehandsandis thusnot effectivein removingpathogens.Soapis seenas aluxuriousandexpensiveitemandnot oftenused.Rubbinghandsis avoidedbecauserightandleft handsshouldbekeptseperate.Childrenarenot encouragedto washhandsbecauseof the deleteriouscoolingeffectsofbothwaterandsoap.

Handwashing;beliefs,practices;Bangladesh

44 Motivating Better Hygiene Behaviour: Importance for Public Health Mechanisms of Change

ANNEX 2

Index to annotated bibliographyHygienic behaviour: Article Numberanimalcontact 9

bathing 9, 14

clotheswashing 14, 20

defecaetionofchildren 15

dishwashing 35

domestichygiene 3,4, 17,23, 29, 37, 47

drainage 45

drinkingwater 22

excretadisposal 2, 9, 44

face washing 31, 32

filtering 5, 12, 30

fly control 9, 44

food hygiene 1, 9,44

food preparation 19

handwashing 1,3,9,10, 11,15, 19, 21,23, 24,25,26, 35, 37,46,47, 50,51, 52, 53

hygienebehaviour 2, 10,26

hygienichandlingof fuel 19

infantfeeding 19

latrineconstruction 36,40

latrinehygiene 19,28, 39

latrineuse 28, 33, 37, 39,47, 51

personalhygiene 17, 23

pit latrines 6, 43

sanitarypractices 1

soil contact 9

washing 9

wastedisposal 2, 15,44

waterconsumption 34,45, 48

waterhygiene 9, 16,44, 51

watersourceimprovement 5

watersources 34watersourceuse 4

waterstorage (16), 19, 28, 30, 34

watersupplyandsanitation 8, 13,41

wateruse 2, 3, 6, 18, 28, 33, 45


‘I

Motivational factors/disease transmission routes/research techniques: Article Numberbeliefs 21,27, 29, 33, 38,52, 53

enablingfactors 1, 2, 4, 6, 7,8, 12, 13, 19,22, 24, 26, 27, 30, 31, 32,40, 43, 45, 50

educationalapproaches 42,49

facilitation ..3, 5, 6, 7,8, 10, 11, 13, 14, 15, 18,20, 21, 25, 26, 28, 33, 34, 35, 39,45,46,47,48,51

influence 1,2,4,5,7,8, 13, 19,27, 31, 32, 36, 38, 39, 40,43,44,46,47

knowledge 9, 17, 30, 32,40

participatoryapproaches 41

practices 15, 17, 29, 33, 52, 53

policy making 37

promotion 37

researchtechniques 29,52

(diarrhoealdisease)transmissionroutes/risks 9, 10, 16, 25,49

understanding 1,2,3,5,6,7,8,9,10, 11, 12, 13, 15, 18, 19,20,23,24,26,27,30,31,33, 34, 35,39, 43,44,47, 50, 51

Countries: Article Numbergeneral 7, 8, 9, 13,27, 37,41, 42

Bangladesh 1, 3, 6, 15,22, 25, 26, 46, 52,53

BurkinaFaso 29

Burma 24

Ecuador 40

Egypt 19,20

Ethiopia 4, 30

Guatamala 10, 11, 17, 28

Haiti 51

India 33, 36,43

Indonesia 2, 34, 39,50

Lesotho 46

Mali 5

Mozambique 14

Nicaragua 38

Nigeria 12,18

Peru 21

Philippines 16

SouthAfrica 44

Tanzania 31,32

Thailand 35

Zaire 23

Zimbabwe 45


For additional information or copies of this report, please write to:

Gourisankar GhoshChief

Water and Environmental SanitationUNICEF

Three United Nations Plaza (DH-40B)New York, New York 10017, USA

J. M. G. van DammeDirector

IRC InternationalWaterand Sanitation Centre

P.O. Box 931902509 AD The Hague,The Netherlands

Motivating Better Hygiene Behaviour:Importance for Public Health Mechanisms of Change

Each year millions of children suffer from diarrhoea and other diseases. Many of thesediseases, and the resulting malnutrition,disability and death, result from risky hygienepractices. Addressing these practices and the associated health problems is of vitalimportance in achieving the World Summit Goals and the Water and Sanitation DecadeGoals set by member countries of the United Nations.

Currently, UNICEF is working towards strengthening the hygiene component in waterand sanitation programmes. Simply, improved water and sanitation facilities do notautomatically lead to their appropriate use and adoption of better hygiene practices.However, conventional hygiene education programmes are not a solution either.

This paper summarizes why conventional hygiene education programmes fail inconvincing people to adopt and use safer hygiene practices. First, fallacies are discussedto dispel myths about hygiene practices and hygiene education.The paper then dis-cusses how people change their hygiene behaviour, as individuals, groups and communi-ties. It also addresses the motivating factors that play a major role in the process ofbehaviour change. It presents two alternative types of hygiene programmes that aimespecially at good practices. Special attention is paid to the roles played by differences insocio-economic and cultural conditions and the reasons fora gender approach in allhygiene programmes.The final chapter provides suggestions for politicians and manag-ers, stressing the need for professional recognition of hygiene, research gaps,and oppor-tunities for information exchange.

Documents

Motivating Better Hygiene Behaviour: • Importance for Public Health